I know it doesn’t make sense, but it feels so real.
I can see it with my two eyes, but I still feel like I need to check.
I get stuck doing compulsions for hours, because it just feels like I never know for sure.
If you relate to any of this, you’ve probably experienced something called Inferential Confusion.
In essence, Inferential Confusion refers to a mix-up between imagination and reality. What could be or could have been with what is and what was. It is the heart of Inference-based CBT, an evidence-based cognitive treatment that focuses on the reasoning process that leads to inferential confusion. In I-CBT, we think of these obsessions as different from random intrusive thoughts that have stuck around. We think of obsessions as an inference- a conclusion that was constructed through faulty reasoning.
Let me give you some examples:
Matt shares with me that he always worries that he might have put poison in his childrens’ food. He states, “I’ve even filmed myself preparing the food just to be safe, and I watch it back, but then I wonder if somehow I erased the footage.” His children are healthy, and his partner has no concerns about their safety. Matt shares that even if someone offered him $1 million dollars if he could truthfully say that he poisoned his kids, he wouldn’t be able to accept it, because he knows that he hasn’t, but he experiences intense distress that he did and somehow doesn’t remember.
The inferential confusion that Matt is experiencing can be broken down into three elements:
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Dismissal of actual evidence
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Over-reliance on possibility
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Irrelevant Associations
Relying on evidence can feel verboten if you’re used to doing ERP. It can feel like using reassurance. One of the main points of OCD treatment, regardless of modality, is to regain trust in yourself. One of the things that Matt is dismissing is his own knowledge that he has OCD and that this doubt is part of the disorder. He is dismissing his own senses when he watches the video playback and sees that he prepared his children’s food without any nefarious intent. He dismisses the evidence that he has no memory of poisoning his children. Importantly, he has dismissed his sense of self and the fact that outside of that OCD Bubble, he considers himself to be a good person and loving father.
I-CBT can address these doubts by helping Matt recognize the reasoning process that creates the doubt in the first place. It is not a way to use logic to dispute the content of his obsessions. Instead, it is a way to use reasoning to change the process that Matt enters into when he experiences these unwanted thoughts.
One aspect of I-CBT is recognizing the differences between obsessional doubt and reasonable doubt. An example of reasonable doubt involving preparing food might be, “I might have added too much salt in the soup.” Reasonable doubt is backed by sense information in the here-and-now. Sense information comprises the five senses, the sense of self, and what we call Common Sense. If Matt were to taste the soup and find that it tasted salty, and read the recipe and see that it called for 1 teaspoon instead of the tablespoon that he had used, he could resolve the doubt. Because reasonable doubt is rooted in reality, it can be resolved through the senses.
Unlike reasonable doubt, however, obsessional doubt is born in the imagination. And because of that, compulsions are never going to resolve the doubt. They’re a real-time solution to an imaginary problem, which is why they never actually help. There is never any actual here-and-now evidence to support the obsessional doubt. Any evidence that seems to justify engagement in the doubt is a result of inferential confusion.
So, once again– resolve the inferential confusion, resolve the doubt—
… and resolve the OCD.
Want to learn more about i-cbt?
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