Common Questions about I-CBT

By Mike Heady, LCPC

What is Inference-Based CBT (I-CBT)?

Inference-based CBT (I-CBT) is a specialized cognitive-based treatment developed specifically for OCD.
Its goal is to target and resolve the faulty reasoning narratives and processes that lead to obsessional
doubts (aka obsessions). If the doubting was resolved, what would be left of OCD?

Isn’t Cognitive Therapy (CT) for OCD ineffective?

I-CBT is not a traditional CT. It does not utilize strategies to dispute or refute the content of one’s
obsessional doubting and it does not prioritize the challenging of post-doubting beliefs and
consequences. It targets the faulty reasoning processes that generate here-and-now obsessional
doubting. In this way, it is primarily a reasoning-focused cognitive therapy.

Does I-CBT utilize exposures?

No. I-CBT is a reasoning-focused cognitive therapy. Deliberate, prolonged in vivo or imaginal exposures
are not a part of the treatment model and not relied upon. Its model is summarized as the knowing
precedes the doing. While there is a case-series published that indicates ERP can reduce inferential
confusion (obsessional doubting) it is not required.

How is I-CBT different from Exposure Response Prevention (ERP)?

The most obvious difference is that ERP is exposure therapy while I-CBT is a specialized cognitive
therapy focused on reasoning. However, when we look more closely at the underlying theories, the
differences become much larger. I-CBT views OCD as a doubting disorder as opposed to ERPs underlying
theory, which views OCD as an anxiety disorder or exaggerated phobic disorder. From an I-CBT lens,
anxiety and compulsions are all downstream byproducts of obsessional doubting and relevant to the
maintenance of OCD but not the central problem. No doubting means no anxiety and no compulsions.

What is the significance of the inference in I-CBT?

This is also another significant departure from other models of OCD treatment. Historically, models
(CBT/ERP and ACT) have suggested that obsessions come about by unwanted thoughts that descriptively
intrude into awareness and are then negatively appraised (Thought-Action Fusion, and the 6 belief
domains). It is this interaction that determines which unwanted thoughts will become obsessions and
which will not. These unwanted thoughts are considered normal and not specific to those with OCD, so
they are not a target for treatment/resolution. Therefore, the endgame for how other models deal with
unwanted thoughts is that they must be accepted and tolerated because they are normal. This is why
they all focus on the emotional and compulsive reaction to the thoughts.
I-CBT, on the other hand, does not see obsessions coming about by negative beliefs about normal
unwanted thoughts. Instead, it argues that obsessions are actually the result of faulty reasoning
narratives that cause one to doubt a circumstance in the here-and-now where no doubt was needed.
This is referred to as an inference of doubt or a decision to doubt arrived at through a reasoning
process. This process is faulty, so the doubt is false. This is referred to as inferential confusion (IC).
Numerous peer-reviewed studies have demonstrated IC to be a more specific predictor of OCD than the
6 belief domains (intolerance for uncertainty, perfectionism, inflated responsibility, overestimation of
threat, over importance of thoughts, and excessive concern about controlling one’s thoughts) as well as
thought-Action fusion beliefs and IC is specific to OCD whereas the belief domains are not.

What is Inferential Confusion (IC)?

Inferential confusion is a confusion between reality and possibility during reasoning which gives undue
credibility to obsessional doubts. A number of reasoning processes that have been identified in the
model exemplify this confusion, which can broadly be categorized as an overreliance on possibility, or
the imagination, and a distrust of the senses and self during reasoning. Fundamentally, the error in
making what is irrelevant in the here-and-now seem relevant and real. There is a psychometrically
validated questionnaire, Inferential Confusion Questionnaire-EV (ICQ-EV) which measures one’s level of
IC. Reductions in the ICQ-EV scores are also correlated to the reduction in Y-BOCS scores.

Doubt vs Uncertainty and Accepting Uncertainty

In I-CBT, the doubt that begins the OCD sequence in the here-and-now is a verb, doubting. Uncertainty
is a downstream experience provoked by the doubting in the here-and-now. If one has not doubted,
then there would be no OCD themed uncertainty. Moreover, because OCD is activated in moments
rather than a 24/7 experience, there is a reality known through one’s 5-senses and common sense prior
to the doubting taking over. I-CBT aims to restore trust in one’s 5 senses and common sense that was
overshadowed by the doubting. In this way, I-CBT says there is certainty that one can reconnect with
and trust no different than those without OCD have about their present moments. Lastly, I-CBT does not
see future abstract possibilities as relevant to OCD. The doubting is activated now, trusted now, and
treated as if real, now. What is happening now is where the problem is. So, while it’s true to say, no one
has certainty about the future, it is also irrelevant if we have doubting happening now that goes against
the 5-senses reality and common sense of now.

Isn’t doubting normal?

I-CBT distinguishes normal doubting from obsessional doubting. Normal doubting arises when prompted
by relevant here-and-now reality. For instance, I see and smell smoke in my house and this leads me to
say what if there is a fire in my house or my doctor discovers a lump and wants to biopsy it, and this
leads me to say what if this lump is cancerous.

Obsessional doubt on the other hand arises from imagined or hypothetical prompts. For instance, upon
receiving my biopsy results where the document states my name, dob, lab tech, and my doctor’s name
along with the results reading benign, I say what if they switched my labs. This doubt was not arrived at
via relevant here-and-now reality. In fact, it was conjured and trusted despite it.
Is I-CBT evidence-based?

Yes. There are over 100 peer-reviewed articles published from different labs. These include theory,
experimental, cross-sectional, psychometric, and outcome trials. Specifically, open-trials, 3 RCTs, and 2
non-inferiority RCTs comparing I-CBT to ERP finishing in 2024. To date, research has only looked at adult
populations.

A comprehensive list of peer-reviewed published research can be found here:

https://icbt.online/publications/

How does I-CBTs outcome data compare to ERP?

Recent meta-analyses (Reid, et al., 2021 and Öst, et al., 2015) and a patient-level mega-analysis
(Steketee, et al., 2019) found CBT/ERP to provide clinically significant change in Y-BOCS scores for 50%
of sufferer’s and treatment response for approximately 60% of sufferers. Open-trials and the 3 RCTs of I-
CBT have all shown similar outcome results where there were no statistically significant differences in
effect sizes between the two. This data prompted researchers to establish a non-inferiority RCT to
demonstrate true equivalence between ERP and I-CBT. To date there are two non-inferiority trials
underway. One in Canada and the other in the Netherlands. Preliminary data from the Canadian trial
shows non-inferiority to ERP.

If I-CBT is evidence-based, why is it not recommended under division 12 of the APA like CBT/ERP is?

I-CBT is a cognitive-behavioral approach, which is a recommended treatment in many treatment

guidelines. However, I-CBT is far more cognitive than any other approach, and so it may need more
specific recommendation in treatment guidelines. Once the non-inferiority trials finish, a meta-analysis
will be conducted, and I-CBT will be submitted for recommendation as an empirically supported
treatment (EST). As it stands, it is an evidence-based treatment for OCD but has yet to be labeled an EST
by the APA.
From: Aardema, F., Bouchard, S., Koszycki, D., Lavoie, M., Audet, J‐S, O’Connor, K. (forthcoming). Evaluation of inference‐based cognitive‐behavioral therapy for obsessive‐compulsive disorder: A multi‐center randomized
controlled trial with three treatment modalities. Psychotherapy and Psychosomatics.

Table 1. Rationale and mechanisms of change in each active treatment (I-CBT, A-CBT and Mindfulness).
Rationale
Inference‐based CBT Appraisal‐Based CBT Mindfulness (MBSR)
‐ Obsessions are faulty inferences of doubt about a possible ‐ Obsessions have their genesis in intrusive cognitions, which ‐ Obsessions are just like any other thought that do not
state of affairs of in reality (what “might be” or “could be”). are random thoughts without inherent meaning. reflect truth or reality or define who one is.
‐ Obsessions are the product of a dysfunctional reasoning ‐ Obsessions develop as the result of dysfunctional appraisals ‐ No specific rationale except that the obsessions are
narrative leading the person to confuse reality with and undue significance given to normal intrusive cognitions maintained by the inability to disengage from them.
imagination (i.e., “inferential confusion”) guided by specific obsessive beliefs.
‐ Dysfunctional reasoning processes that give rise to a state ‐ Obsessive appraisal and belief domains leading intrusions to ‐ The inability to decenter from obsessional thoughts
of inferential confusion characterized by an overreliance on develop into obsessions revolve around over‐responsibility, results in lack of cognitive flexibility and perspective
possibility and a distrust of the senses and/or self during overestimation of threat, over‐importance given to thoughts, taking that contribute to maladaptive self‐regulation
reasoning, including 1) inverse inference, 2) dismissal of control of thoughts, perfectionism and intolerance of processes and behaviours.
sense information 3) irrelevant associations uncertainty
‐ Vulnerable self‐themes and feared self‐perceptions ‐ A lack of (self‐) confidence in memory, decision making and ‐ Lack of awareness and attention regulatory skills may
underlie obsessional narratives information processing may underlie obsessions. underlie the cycle of obsessions.
‐ OCD primarily follows a non‐phobic model of development ‐ OCD primarily follows a phobic model development similar to ‐ No specific underlying model of development for OCD
similar to overvalued ideas or delusions through other anxiety disorders through the significance attached to except that lack of mindfulness perpetuates intolerance
dysfunctional reasoning and personal investment in intrusive cognitions and the reinforcing role of anxiety and of obsessions and reflexive patterns of reacting to them.
obsessional doubts that gives rise to unsuccessful avoidance behaviors (cognitive and overt avoidance,
neutralizing and avoidance behaviors. neutralization, safety‐seeking behaviors).
‐ Treatment is based on a constructionist model, where ‐ Treatment is based on a mediational realist model where ‐ Based on Buddhist methods mind training to reduce
obsessional doubt is generated inside the person without obsessions result from a reaction to, and avoidance of, an suffering. Suffering occurs when one lacks awareness of
mediation. The person rehearses obsessional doubt during intrusion or an ambivalent or uncertain state of affairs in automatic and distorted patterns. Mindfulness training
neutralization while being disconnected from the senses or reality. Avoidance prevents disconfirmation of the perceived teaches people to step out of automaticity and respond
authentic self that normally would invalidate the doubt. threat or dysfunctional appraisal in response to the intrusion. to difficulties with acceptance, equanimity and wisdom.
Primary hypothesized mechanisms of change
‐ The primary mechanism of change is modifying the ‐ The primary mechanism of change is the modification of ‐ Primary mechanisms of change are acceptance, openness
inferential confusion process that gives credibility to appraisals of significance of what otherwise would be usual, and flexibility through a non‐judgmental observer or meta‐
obsessional doubt. In turn, this allows for the resolution of unproblematic intrusions. In turn, this allows for the cognitive stance towards experience. This conscious and
obsessional doubt, its imagined consequences, distress and normalization of obsessions, reducing distress and the need detached stance attenuates distress and urge to engage in
compulsions. to engage in compulsive rituals. rituals as the obsessions become less salient and more
tolerable.
‐ Modification of feared‐self perceptions and self‐themes ‐ Modification of core beliefs and self‐schema underlying ‐ Developing a mindfulness stance facilitates building self‐
underlying obsessional narratives through the realization dysfunctional appraisals, including increasing self‐confidence compassion, kindness, self‐understanding and self‐trust.
that OCD represents a false self while repositioning the and awareness that symptoms inhibit the self by limiting
person back towards their authentic and real self social, leisure or work activities
‐ Reducing neutralization and avoidance leads to less doubt as ‐ Reducing neutralization and avoidance leads to cognitive ‐ Reducing neutralizations and avoidance facilitates full
these constitute rehearsing doubt and prevent the change as it normalizes anxiety while increasing the intensity engagement with painful experiences as they arise. Facing
assimilation of sense information that resolves the doubt. and frequency of obsessions without the occurrence of and exploring obsessions and distress consciously and with
Certainty already exists before the doubt, and therefore feared consequences. Obsessions are normal thoughts and detachment facilitates perspective taking, extinction of
neutralization and avoidance are unnecessary. neutralization and avoidance are unnecessary. habitual reactivity, and adaptive coping and behavior.
From: Aardema, F., Bouchard, S., Koszycki, D., Lavoie, M., Audet, J‐S, O’Connor, K. (forthcoming). Evaluation of inference‐based cognitive‐behavioral therapy for obsessive‐compulsive disorder: A multi‐center randomized
controlled trial with three treatment modalities. Psychotherapy and Psychosomatics.

OSM Table 2. Principal treatment targets and techniques in each active treatment (I-CBT, A-CBT and Mindfulness).

Principal treatment targets and techniques

Inference‐based CBT Appraisal‐Based CBT Mindfulness (MBSR)
The principal treatment target in I‐CBT is focused on the initial The principal treatments targets in A‐CBT are focused on the The principal target of mindfulness training is the cultivation
obsessional doubt (e.g., “I might be contaminated,” “I might significance attached to intrusive cognition and the avoidance of conscious awareness of present moment experiences (i.e.,
have forgotten to lock the door”) preceding the occurrence of and compulsive behaviors caused by these appraisals. Its thoughts, feelings and sensations), coupled with an accepting
feared consequences, appraisals, distress and compulsions. cognitive component aims to normalize the experience of and non‐judgmental mindset. Mindfulness training modifies
Its techniques aim primarily to resolve the obsessional doubt intrusive cognitions based on the notion that the initial how one relates to internal experiences without attempting to
by recognizing it reflects confusion between reality and the intrusions and doubts are normal, but escalate into obsessions alter them. One learns to see internal experiences as objective
imagination, which renders it entirely irrelevant to the here‐ as the result of how they are appraised. Its behavioral events of the mind rather than personally identifying with
and‐now. The consequences of obsessional doubt are only component has a more explicit focus on all forms of avoidance them.
secondary targets based on the premise that once you resolve and compulsive behaviors through behavioral exercises that
the initial doubt, this should logically also resolve all symptoms include reality testing and/or formal exposure and response
that follow from the doubt, including feared consequences, prevention (ERP).
anxiety and neutralizations.
Psychoeducation, techniques and interventions
 Increase awareness of the obsessional sequence, which  Normalization of unwanted intrusive thoughts that are  Psychoeducation on mindfulness to improve well‐being
starts with obsessional doubt. universal, meaningless and normal, but develop into through acceptance of difficulty experiences, disengaging
 Teach the difference between normal and obsessional obsessions as the result of specific appraisal and beliefs. from unhelpful thoughts, emotions and behaviors, and
doubts.  Psychoeducation about the counterproductivity of moving towards living one’s life fully and skillfully
 Identify the reasoning narrative that leads up to the controlling thoughts, as well as neutralizing compulsive  Formal training in focused attention and open
obsessional inference of doubt. behaviors. monitoring of moment‐to‐moment experiences and
 Highlight the imaginary construction of obsessional doubt  Identification of specific appraisal and belief domains informal practices to cultivate mindfulness in daily
as it occurs in the “here‐and‐now.” producing distress and compulsive behaviors in response to routine activities. Formal mindfulness practices, including
 Recognize the confusion between reality and imagination, intrusive thoughts, including 1) inflated responsibility, 2) the body scan, mindful yoga and walking, and sitting
rendering obsessional doubt irrelevant to the here‐and‐ overestimation of threat, 3) over‐importance given to meditations.
now. thoughts, 4) importance of controlling thoughts, 5)  Psychoeducation on stress, hyperarousal, and responses
 Develop and practice alternative narratives grounded in intolerance to uncertainty and 6) perfectionism. that compromise well‐being and the application of
common sense and reality.  Modification of obsessive belief and appraisal domains mindfulness skills to everyday activities and real‐life
 Identify and address specific reasoning errors that render through cognitive restructuring methods, including Socratic stressors.
the obsessional doubt false and irrelevant. dialogue, downward arrow, thought monitoring, examining  Application of mindfulness skills to obsessions and
 Highlight the selectivity of the obsessional doubt. the evidence. compulsions. Includes increasing awareness of one’s
 Identify the cross‐over point into the obsessional doubt  Repeated and sustained exposure and response prevention experiences, accepting one’s experience as it unfolds,
and learn how to stay with the sense and common sense during and in between sessions combined with behavioral investigating one’s experience with curiosity and
where certainty already exists. experimentation to disconfirm and modify appraisals of openness, taking an observer and detached stance with
 Identify the feared self that represents a false self, and significance and obsessive beliefs (i.e., hypothesis/reality one’s experiences
reposition the person back to their authentic self by testing). Exposure includes covert (i.e., thoughts, scenarios,  Promote flexibility and acceptance of thoughts and inner
building up a picture of mundane self‐attributes. mental images, and mental rituals) and overt (i.e., experience, while concentrating on achieving goals in a
 Improve self‐trust through reality‐sensing by acting in compulsions, safety‐seeking strategies) behaviors. mindful conscious way
accordance with the knowledge that the obsession is  Identification and modification of core beliefs and or fixed  Applying mindfulness to enhance compassion and
false, the obsession, or the obsessional doubt. behavior patterns contribute to symptoms, including acceptance towards oneself and others, mindful
encouragement of lifestyle changes communication, and mindfully changing life styles
From: Aardema, F., Bouchard, S., Koszycki, D., Lavoie, M., Audet, J‐S, O’Connor, K. (forthcoming). Evaluation of inference‐based cognitive‐behavioral therapy for
obsessive‐compulsive disorder: A multi‐center randomized controlled trial with three treatment modalities. Psychotherapy and Psychosomatics.

Table 3A. Potential areas of overlap and distinctions (I-CBT vs A-CBT)

Inference‐based CBT versus Appraisal‐based CBT

“Reality sensing” vs. “Reality testing”
Reality sensing in I‐CBT has an overlap with reality testing in A‐CBT given that both are exercises with a behavioral component where the person
approaches obsessional situations. In I‐CBT, the person is asked to act upon the knowledge that the initial obsessional doubt is false while
trusting one’s authentic self when encountering triggering situations. In A‐CBT, the person is asked to test out obsessional beliefs and appraisals
by engaging with an obsessional situation without neutralizing allowing for the person to disconfirmed feared outcomes. Hence, while the overt
behavior is similar in treatments, the aims and rationale of the exercises are distinct with a focus on disconfirming and refuting appraisals in A‐
CBT and a focus on doing things normal without a putting in any unnecessary effort in I‐CBT. However, like in reality testing, there is a behavioral
component to reality sensing that may be related to an unknown or overlapping mechanism of change during treatment. Both techniques may
also allow the limbic system to experientially process situations to develop more adaptive mental representations without lack of threat.

“Neutralization” versus “Neutralization”

Both I‐CBT and A‐CBT recognize the importance of addressing neutralization and compulsions as a factor in maintaining symptoms, albeit with
some distinctions in conceptualization. I‐CBT views covert and overt neutralization primarily as acting upon doubt that is irrelevant to here and
now. A‐CBT views neutralizations and attempts to control thoughts as counterproductive because they maintain dysfunctional beliefs and
distress. However, both approaches may directly ask the client to not engage in neutralizations. In I‐CBT, the person may be asked not to engage
in neutralization rituals as part of reality sensing which asks the person to do things normally without any additional effort. Similarly, A‐CBT may
ask the person not to engage in neutralizing activities through reality testing, or as part of an ERP‐based rational (i.e., response prevention). The
latter involves purposely inducing anxiety in clients, which is not an intended effect of reality sensing, since its goal is to do things normally, and
this includes not engaging with obsessional doubt and feeling anxious as a result. However, reality sensing in I‐CBT may also be accompanied by
distress if the person does not succeed to do things without doubt and engages in neutralizing activities.
“Faulty reasoning processes” vs. “Cognitive distortions”
Cognitive distortions and processes are addressed in both I‐CBT and A‐CBT. I‐CBT focuses on the reasoning process of inferential confusion (i.e.,
confusion reality with imagination) hypothesized to result in obsessions while A‐CBT may address Beckian cognitive distortions as part of the
dysfunctional appraisal of intrusive cognitions. However, I‐CBT is more process than content‐oriented with its focus on the reasoning process of
inferential confusion as a crucial factor in symptom development, which is claimed to be distinct from the cognitive distortions addressed in A‐
CBT. In comparison, A‐CBT tends to be more content‐oriented with its focus on the content of specific beliefs of appraisals considered relevant
to OCD in line with the cognitive specificity hypothesis, which states that psychological disorders can be defined by their cognitive content.
“Feared selves” vs. Self‐schema“
I‐CBT focuses on the role of vulnerable self‐themes and feared self‐perceptions, whereas A‐CBT may focus on self‐schema or core beliefs relating
to the self. In A‐CBT, this is usually a general approach to identifying behavior patterns, whereas, in I‐CBT, the feared self is hypothesized to
cover up the person’s actual self. In addition, I‐CBT conceptualizes feared self‐themes as dictating the content and occurrence of obsessional
doubt, whereas A‐CBT considers only the self in terms of the personal significance attached to intrusive thoughts. Nonetheless, both I‐CBT and
A‐CBT consider ingrained or deep‐seated core beliefs about the self or the world contributing to symptoms.
“Self‐Doubt” versus “Lack of confidence”
In I‐CBT, the obsession begins with the primary doubt which typically reflects a feared self that stands in sharp opposition with their real or
authentic self. In other words, I‐CBT considers a distrust of self or self‐doubt as an important feature of OCD. Consequently. I‐CBT aims to
reposition the person back to their authentic self and increase self‐trust by acting in accordance with one’s actual self during reality sensing to
counter self‐doubt. Similarly, in A‐CBT, there may be the view that people with OCD lack confidence in memory, that doubt is threatening, and
lack cognitive confidence in their decisions and information processing. As a result, they may also lack self‐confidence. So, there may be
techniques to encourage confidence in self and decision‐making in A‐CBT that share similarities with the focus on increasing self‐trust in I‐CBT.
Other similarities and differences
● Both A‐CBT and I‐CBT share general common factors that exist across most psychotherapies including building a working alliance, sharing
hope, guidance, empathy, therapist experience and a structured approach towards emotion management. Both approaches also identify
avoidance and family accommodation as important factors to address in therapy.
● A‐CBT may also encourage a lifestyle change and undertake enjoyable leisure pursuits to counterbalance OCD activities. Similarly, I‐CBT
would encourage activities in accordance with the person’s authentic self to fill up the void left behind by OCD once symptoms begin to
retreat.
● Both approaches also emphasize similar factors in relapse prevention, namely: identifying high‐risk situations, mood and stress triggers,
and keeping up with practice exercises.
● I‐CBT does not challenge the specific content of beliefs or values. It only addresses the process by which obsessional doubt comes about,
rendering it false and irrelevant. A‐CBT typically does address the content of beliefs and may also address traits and values that contribute
to the dysfunctional appraisal of intrusive cognitions (e.g., intolerance for certainty, perfectionism, over‐responsibility). I‐CBT does consider
content in terms of feared‐self themes that may dictate the content of individual obsessions or symptom dimensions of OCD.
From: Aardema, F., Bouchard, S., Koszycki, D., Lavoie, M., Audet, J‐S, O’Connor, K. (forthcoming). Evaluation of inference‐based cognitive‐behavioral therapy for
obsessive‐compulsive disorder: A multi‐center randomized controlled trial with three treatment modalities. Psychotherapy and Psychosomatics.

Table 3B. Potential areas of overlap and distinctions (A-CBT vs Mindfulness)

Appraisal‐based CBT versus Mindfulness (MBSR)

“Thoughts are just thoughts” vs. “Defusion”
A‐CBT conceptualizes obsessions as originating from normal, universal intrusive thoughts that are given too much significance and importance.
Thus, a central focus of A‐CBT lies in the active normalization of thoughts, helping clients to treat thoughts as just thoughts and taking a more
metacognitive stance towards them instead of getting overly preoccupied with them. Similarly, mindfulness focuses on reducing the importance
given to thoughts by promoting an observer stance towards thoughts without attachment, aversion or mental proliferation. While both address
thoughts, the difference is that in A‐CBT, the techniques are practiced as a way of disengaging from the OCD symptoms and reframing the
appraisal of thoughts, whereas mindfulness training helps one to see thoughts as objective events in the mind rather than personally identifying
with them. The role of systematic countering of dysfunctional thoughts is becoming less prominent in A‐CBT, as both A‐CBT and MBSR are
modalities to conclude that thoughts are harmless.
“Letting thoughts pass” by versus “Letting go”
In line with the notion of treating thoughts as just thoughts, A‐CBT helps clients learn that obsessions pass by, whereas mindfulness similarly
helps clients to see their thoughts as transient events. However, in A‐CBT, this is achieved by helping clients appraise these thoughts as normal
and non‐significant, whereas mindfulness training aims to change one’s relationship with thoughts without attempting to modify them.
“Exposure” vs “Acceptance”
Both A‐CBT and mindfulness tend to address avoidance similarly, especially when applying exposure. For example, in A‐CBT, clients are asked
to expose themselves to their obsessions and feared stimuli without engaging in compulsions or any related avoidance in order to habituate to
the anxiety. Similarly, in mindfulness, clients are asked not to avoid or suppress distressing thoughts and emotions but to remain open, curious,
and accepting of them. In mindfulness training, clients are encouraged to turn towards and accept difficult and unpleasant experiences but not
to react to or engage in them. They are also asked to remain fully present when engaging in various behaviors, without being distracted or
engaging in neutralization strategies. Given that this is carried out over long periods, these techniques share similarities in underlying exposure
mechanisms and are both experiential exercises. However, in mindfulness, the difference is that these strategies are part of a meditative
technique focused on limiting experiential avoidance and habitual reactivity patterns, whereas in A‐CBT, the focus is on learning principles (e.g.,
inhibitory learning, information processing, emotional processing, habituation).
“Paradoxical intent” versus “Thought suppression”
Both mindfulness and A‐CBT recognize the role of neutralization and compulsive behaviors as counterproductive and that in order to gain
control, one has to give up control. Mindfulness utilizes paradoxical intent where the person is asked to allow thoughts to come into awareness
without trying to control or suppress them with the ultimate aim of being able to disengage from them or tolerate them. Similar exposure
strategies can be observed in A‐CBT, where the person is asked not to suppress or resist thoughts to conclude that they are harmless. The same
general principles apply to other neutralizing behaviors and overt compulsions, although in mindfulness, the person is usually asked to observe
these compulsive behaviors non‐judgementally initially before giving them up.
“Reality testing” vs. “Staying with the five senses”
The concept of “reality testing” or “hypothesis testing” shares a superficial similarity with staying with five senses during mindfulness practice.
However, in A‐CBT, these behavioral experiments have the explicit aim to change one’s expectations and anticipation of adverse outcomes when
not engaging in rituals and compulsions. In mindfulness, unless combined with cognitive interventions, staying with the five senses in
mindfulness does not have the explicit aim to reevaluate the appraisals of intrusive cognitions. However, reality testing and staying with the
five senses may be similar to the extent that both involve exposure to fearful stimuli.
“Changing lifestyle” versus “Living Mindfully and Skillfully ”
A‐CBT may encourage a change of lifestyle and undertaking enjoyable leisure pursuits to replace the time consumed by the OCD. Similarly,
mindfulness training teaches one to embrace life fully with a sense of clarity, wisdom, and joy, to be mindful in interactions with others, to
cultivate a positive mindset, and to nurture calmness, self‐compassion and self‐acceptance. However, the focus on engaging and maintaining a
healthy global lifestyle is significantly smaller in A‐CBT.
Other similarities and differences
● Both A‐CBT and mindfulness consider a preoccupation, lack of distance (i.e., “fusion”) and giving (intrusive) thoughts too much importance
to be at the root of obsessions. Consequently, both teach distancing from thoughts, detachment from emotional reactions, accepting
thoughts and letting them go non‐judgmentally, taking an observer position, and facing the problem and experience. The principal
difference is that these focused are part of a meditative technique in mindfulness, whereas in A‐CBT, these techniques are taught to
disengage with the OCD through a more functional appraisal of thoughts.
● The focus of A‐CBT on learning highlights which strategies can subtly contribute to avoidance (e.g., when touching a dirty object, focusing
on defusing thoughts instead of accepting and being mindful of the situation). The focus of mindfulness on acceptance and a meditative
stance guide therapists away from engaging in emotionally detached and complex cognitive debates (e.g., when touching a dirty object,
focusing on restructuring the probabilities of catching or transmitting diseases).
● Both A‐CBT and mindfulness share general common factors that exist across most psychotherapies including building a working alliance,
sharing hope, guidance, empathy, therapist experience and a structured approach towards emotion management. Both approaches also
identify avoidance as an important factor to address in therapy.
From: Aardema, F., Bouchard, S., Koszycki, D., Lavoie, M., Audet, J‐S, O’Connor, K. (forthcoming). Evaluation of inference‐based cognitive‐behavioral therapy for
obsessive‐compulsive disorder: A multi‐center randomized controlled trial with three treatment modalities. Psychotherapy and Psychosomatics.

OSM Table 3C. Potential areas of overlap and distinctions (Mindfulness vs I-CBT)

Mindfulness versus Inference‐based CBT

“Staying with the five senses” vs “Reality sensing”
Mindfulness practice includes staying with the five senses in the here and now, which has similarities the I‐CBT notion of using the senses to
detect reality, both inner and outer. But there are some distinctions in the rationale and content of the exercises. In I‐CBT, reality sensing is
intended to stop the person from going into the imagination and encourage them to relate to the world as they already do in non‐obsessional
situations. Trusting the senses and self goes along with abandoning the reasoning behind doubt and investment in remote or imaginary
possibilities. It does not require learning new skills or acting unusually. In mindfulness, using the five senses is part of learning a meditative
technique of being present in the here‐and‐now.
“Observer stance” versus “Metacognitive insight”
Similar to taking an observer position in mindfulness, I‐CBT includes increasing awareness of obsessional and normal thinking to improve
cognitive insight. The main reasoning process in I‐CBT held responsible for the obsession (confusion between reality and imagination) also
requires a meta‐cognitive stance to gain insight into. Further, in the course of I‐CBT, various exercises involve observing, rather than reacting
to thoughts, including identifying the obsessional sequence, telling the difference between normal and obsessional doubt, and learning to
identify the cross‐over point from reality into imagination. However, I‐CBT utilizes these strategies with the ultimate aim of recognizing the
falsehood of the obsession and rejecting these thoughts. Mindfulness would encourage acceptance of thoughts to be able to let them go or
tolerate them (i.e., paradoxical intent).
“Neutralization” versus “Neutralization”
Both mindfulness and I‐CBT address neutralization, but with different rationales. In mindfulness, neutralization and compulsive behaviors are
viewed as antithetical to mindfulness as these represent fusion experiences, which are the opposite of defusion. It would ask the person to take
a metacognitive stance to help the person let go of unhelpful thoughts and behaviors according to their values and goals. Therefore, the
philosophy is to accept the obsessions and compulsions, see how they are furthering one’s goals or not, and perform the rituals mindfully rather
than automatically, slowing them down and rendering them more irrelevant to the here and now. In I‐CBT, neutralization is viewed as rehearsing
the doubt and changing reality based on imaginary doubts. The result is that neutralization sabotages the goal they are supposed to accomplish.
Consequently, I‐CBT focuses on bringing the person back to reality through the realization that the doubt is imaginary, the rehearsal of reality‐
based alternative narratives, and reality‐sensing exercises that involve acting without additional effort.
“Self‐Compassion” versus “self‐trust”
In mindfulness, there is an emphasis on self‐compassion and trusting the self or experience by accepting experience without judgment. In I‐
CBT, there is also a strong focus on learning how to trust the self and the senses, given that a distrust of the senses and the self is an integral
part of the inferential confusion process. However, in mindfulness, trusting the self is part of a meditative technique, whereas in I‐CBT it is an
explicit mechanism of change that goes along with abandoning the reasoning behind doubt and investment in remote or imaginary possibilities.
Other similarities and differences
● In mindfulness, the point is to stop struggling unhelpfully against an obsession, accept it non‐judgmentally and subsequently carry on
normally. In I‐CBT, a hallmark point is that the person does not do anything special or extra but uses their five senses and common sense
in OCD situations, exactly as they do in non‐OCD situations. In other words, people with OCD already possess the skills to use their senses
in the correct way but not in the correct context.
● In I‐CBT, the person has a vulnerable self‐theme or a feared self‐identity that the person imagines they may become (but never will) making
them more vulnerable to symptoms of OCD. Hence, I‐CBT is focused on reorienting the person towards their real self. In mindfulness,
clients are also encouraged to focus on their goals and the positive self‐confidence they feel for their achievements, but not with the explicit
aim of dissolving a feared self that covers up their real self,
● In mindfulness, similar to A‐CBT, a lack of distance and preoccupation with (intrusive) thoughts is at the root of obsessions. However, in I‐
CBT, obsessions are considered false inferences that need to be rejected rather than accepted as just another thought.
● I‐CBT, values, morals, ethical and social, or goals in life are not explicitly addressed. Rediscovering the authentic self relates to rediscovering
observable and mundane aspects of self that often stand in sharp opposition to the person’s feared self.
● Both I‐CBT and mindfulness share general common factors that exist across most psychotherapies including building a working alliance,
sharing hope, guidance, empathy, therapist experience and a structured approach towards emotion management. Both approaches also
identify avoidance as an important factor to address in therapy.