ERP vs I-CBT In the treatment of OCD

Why ERP and I-CBT are stronger together

by Daniel Frazer, LCSW 10/30/2025

Exposure Response Prevention is the gold treatment standard for Obsessive Compulsive Disorder, widely understood to help clients face their fears and discomfort systematically and allowing the individual to deprogram their cyclical fear. However, while ERP addresses the avoidance and the emotions, it may not always help reconnect clients with their value systems. 

First, let’s define values as the term in OCD treatment may have some differences than what you’re used to.  

Values can be understood as that which remains constant, which speak to our sense of need, belonging and our identity. Values in the context of OCD are not dissimilar to core beliefs – they’re what we do not question and what remains as a constant in our lives. 

I-CBT helps to identify the way our thoughts are in error and pull us away from our values. I-CBT stands for Inferential Cognitive Behavioral Therapy. I-CBT is a more recent but rapidly growing approach to working with OCD that is focused more on the thoughts, thinking-errors and values behind OCD.

Let’s take JD for example:

JD is a loving father of a newborn, is gainfully employed as a history teacher and he and his wife have been together for years and have enjoyed a successful marriage where they calmly make decisions together and recently purchased their first home. JD is well recognized and respected in his community and for the most part, JD loves the life he’s privileged to have. 

However, JD has a lifelong secret. 

Constantly over the years, JD has questioned if he’s actually a horrible person: a monster, even. Recently when watching a Netflix horror film, JD was concerned why he wasn’t as sickened by the gore as his wife was. Where his wife was disturbed and grossed out, JD felt initially rather bored and even found some of the scenes a little funny even if that wasn’t their intent.

Where most would have chocked this up to bad acting, too much CGI or simply having seen too many horror flicks, JD asked himself…”Why?”

“Shouldn’t I be disgusted? Am I not disgusted because I’m actually a psychopath?” 

JD thought back to serial killer documentaries he’d seen where the killers in question reveled in gross, abhorrent actions. JD was terrified that he may too be some kind of socially abhorrent monster.

Let’s frame this in the context of OCD using I-CBT.

We have the initial trigger of the horror film. Let’s think of the trigger as, for the most part, a constant often neutral variable that we may have a reaction to. We can not control triggers – we can avoid them, but we can not control them. The person with OCD that has what we call an "obsessional doubt” The obsessional doubt is the narrative or question which arises within us once we’ve encountered the trigger. JD asked himself: “Shouldn’t I be disgusted? Am I not because I’m a psychopath?” Having this thought then leads JD to quickly jump to conclusions and feel terrified of the prospect of being a psychopath. Upon recognizing this possible consequence of his obsessional doubt, JD feels terrified at this prospect of being someone so abhorrent. He then makes it a point to do numerous behaviors to prove he’s not a psychopath – he might do a lot of research on psychopathy, test himself with horrible imagery expecting a response or he might even avoid all media and news in general to avoid even thinking about the possibility of being a psychopath. These are the compulsions. 

ERP would recognize JD’s difficulty in accessing provocative stimuli and do the opposite. In ERP, we might purposely expose JD to watching increasingly disturbing material and learning to tolerate the fear of being a psychopath with increasingly difficult stimuli. Eventually, JD would have tolerated so much difficult material that he is nowhere near as negatively aroused.

But, is this enough?

If we go back to the story of JD, a few things stand out. JD reacted to a thought he had. JD can think anything but the part of his brain wired for safety decided to react to an internal narrative with faulty reasoning. All this time, JD is actually reacting to a thought standing in contrast to his values of being a hardworking, loving husband and valued member of society i.e. a psychopath. 

In I-CBT, we lead with this cognitive chain and use it to frame any further work we need to do in order to lower the nervous system response. Where ERP is more reactionary and experiment based, I-CBT starts as a sort of meditation on our thoughts and a way to recalibrate our thinking to better align with what is provable and who we are. 

In working with JD, we’d still likely use ERP, however, we’d utilize ERP when we first thoroughly understood how the system of doubt for JD’s OCD works. The goal of I-CBT is for JD to independently be able to recognize how his OCD is working against what is provable, observable and known for him and to utilize tools (such as ERP and others) to help concretize these values.

In the OCD treatment community, there is some debate over I-CBT vs ERP as the primary treatment for OCD. This is particularly nuanced when we look at more thought based OCD systems such as harm based or existential OCD where replicating the feared outcome with ERP may be more challenging. Strong proponents of ERP will suggest that I-CBT is too thought based and inherently avoidant of the doubt that JD feels. However, this fails to recognize that in the the reality of good OCD treatment, we’re loyal to client outcomes, not modalities, and combining multiple evidence based approaches for OCD to work synergistically is how we institute real change.

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Disclaimer:

All case examples or client descriptions used in this blog are fictional and created solely by the author for educational purposes. They are not based on real individuals. Any resemblance to actual persons, living or deceased, is purely coincidental.