Uncertainty, Core Fears, and I-CBT
In the last article, I dove deeper into some of the common features and experiences of Harm OCD, Perinatal OCD, and Pedophilia OCD. Yes, all of these subtypes share a common theme: paralyzing doubts and fears of committing some kind of violence against something you don’t want to. In hearing about the experiences of these subtypes, a response from the ignorant non-suffer would probably fall into two categories:
catastrophizing (“What?! Why in the hell would you think that?! I wouldn’t tell anyone about that… Keep that to yourself”)
OR
discounting (“Come on, why is that even scary in the first place? Why would you ever doubt your inner intentions? Of course you must know that you don’t want to do that”).
It is this latter response which I want to explore. After all, why are obsessions, across all types, so scary and distressing in the first place? What is it about them that grants them the power to wreak havoc on our self-concept, contentment, and peace of mind? There are a few interesting theories and perspectives on this answer, and I’m going to try to cover a few prominent ones.
Core Fears
Every obsession most likely has a trigger, be it something you come into contact with in the natural world (i.e. something you see, hear, or feel with your senses) or some kind of mental phenomena (i.e. a thought, feeling, sensation, or urge). For instance, having intrusive fears or doubts of whether or not you ran over someone after passing by a certain stoplight, having an intrusive thought of stabbing yourself after seeing a knife, or feeling like something doesn’t sound or feel “just right” after reading a certain phrase on the internet. It is not these exact triggers that per se what make OCD OCD, but rather it is the implications, meanings, and doubts we derive from their emergence that begets suffering.
Take two people who say they have the same fleeting intrusive thought of impulsively turning into oncoming traffic while driving down the highway. Person A notices the thought and just thinks “Woah weird” and goes back to singing Chappell Roan. Person B on the other hand, notices that thought and then thinks “Why did I think that? Do I really want to commit suicide?”. They’ll probably start to feel anxious and may even pull over to give themselves a break to make sure they don’t do anything rash. This could even lead to a severe fear of driving, driven by the core fear of what if I accidentally or impulsively lose control and turn into oncoming traffic? From an ERP perspective, it is this core fear, planted by the seeds of intrusive thought, that drives the OCD cycle. You may have noticed that I’ve been bolding and italicizing certain phrases in these articles. These aren’t random, but rather are meant to highlight the features of uncertainty that are a part of the OCD experience. What’s interesting is that, similar to how OCD symptoms themselves fall into certain categories, it turns out that the core fears and doubts underlying intrusive thoughts also fall into certain categories.
According to Dr. Jonathan Greyson, there are 7 different types feared consequences of obsessions (Greyson, 2014):
Fear of harm to oneself and/or to others
Fear of what a thought or action might mean
Fear of forgetting and/or loss
Fear of misperceptions and/or misunderstandings
Fear of anxiety or other uncomfortable feelings resulting from the obsession and/or not experiencing feelings the “right way”
Fear of constant attention to thoughts or images and/or constant perception of bodily sensations
Fear of imperfection
Of course, there are most likely others to add, but this list provided an interesting framework for making sense and easily identifying why an obsession is so scary in the first place.
In ERP, the first part of OCD treatment is first getting a general list of what exact intrusive thoughts you experience, the triggers in which they tend to occur, and then identifying the core fears underlying each of these intrusive thoughts. It is this core fear, within the lens of ERP, that exposures aim to test, challenge, and explore, and the success or failure of an exposure most likely depends on the degree to which it correctly targets the exact core fear underlying an obsession. For example, if my core fear underlying my intrusive thoughts is that I am going to impulsively stab or molest my dog, then setting a time for 5 minutes and caring for them would be a pretty good exposure for that core fear. After enough times, I’ll habituate, start to build trust in myself (safety learning), and learn to brush off those intrusive fears. This is not different from, say, a fear of dogs. If I am terrified of dogs, because I’m afraid they’ll bite me, gradually exposing myself to a dog, by first watching a video of dog, then hearing barking sounds, then going to a dog park, and then finally going over to that friends house I’ve been avoiding, slowly reduces both my anxiety response and the idea that dogs are dangerous. The same is with OCD. By intentionally approaching the subject or anchor of my obsessions, I can learn that the thought is nothing to be afraid of.
A Different Perspective
The idea that feared consequences and appraisals of obsessions drive OCD is a well-accepted and understood idea within the OCD community. However, there has been an emerging model of OCD treatment called I-CBT (Inference-Based Cognitive Behavioral Therapy) that offers a really different and interesting perspective. Within this framework, the driver of OCD isn’t feared consequences of intrusive thoughts, but rather doubt itself. This may get a little hairy, but bear with me. Within the I-CBT framework, obsessional doubt is thought of as the core driver of OCD, and the central focus of treatment is to target and cultivate insight into the causes of obsessional doubt itself (Aardema, 2024). Within the I-CBT framework, obsessional doubt differs from non-obsessional doubt in two ways difficulty trusting one’s senses and reliance on story (vs reality). For instance, the way we typically pacify and settle doubt is through confirming with our senses: If I doubt whether or not I locked the door, checking the door with my senses (seeing and feeling), and then trusting what I see and feel is mostly enough to quell my doubt. Non-obsessional doubt is often pacified by using our senses to confirm reality in the here and now, yet, in OCD, doubt is based on a reasoning narrative rather than reality itself (Aarmeda, 2024). Because of this, there is no amount of checking, reassurance seeking, or compulsions that could ever pacify, or quell the anxieties driven by this doubt, because they are based in story and possibility, rather than in reality or the present moment (Aarmeda, 2024). This confusion and blurring between story from reality, is what is termed inferential confusion, and is the central target of I-CBT. From this perspective, obsessions aren’t thought of as random unwanted mental intrusions, but rather as feared possibilities that have an identifiable and understandable reasoning process behind them (Aarmeda, 2024).
But then what? From an I-CBT perspective, the process of dismantling the reasoning processes underlying the obsessional doubt (inferential confusion) is the core treatment target and key to long-term recovery, rather than challenging the feared consequences via exposure to triggers and ending avoidance behaviors in ERP. The symptoms and components of the OCD cycle (triggers, intrusive thoughts, core fears, and safety behaviors) are what I-CBT terms the “Outer Wheel” of OCD - the symptoms and components of OCD that are driven by the “Inner wheel” components - the reasoning factors that gives birth to obsessional doubt that drives the OCD cycle (Aarmeda, 2024).
You could think of I-CBT as an additional layer to ERP, targeting the “C” component in CBT and ERP the “B”. In ERP, the treatment targets are two fold: safety behaviors and the anxiety response itself, with the idea that through exposure to triggering and distressing thoughts, coupled with refraining from engaging in compulsions, you promote safety learning, habituation, self-confidence and increase tolerance to uncertainty. Yet, in I-CBT, the focus is on targeting uncertainty itself - the obsessional narratives and doubts - and dismantling the reasoning processes that give rise to these doubts in the first place, with the aim of promoting insight, self-compassion, and subsequent extinction of the “Outer Wheel” factors (i.e., feared consequences, compulsions, and anxiety) (Aarmeda, 2024). This is a new and emerging model of OCD treatment, and I’m still new to these ideas and have much to learn, so in the coming articles I’m going to try to break down these concepts with more clarity and conciseness and offer some tangible strategies/practices that hopefully you could implement yourself. But, for now, this may serve as a general high level comparison between ERP and I-CBT. For more information on things I-CBT, check out this website: https://icbt.online/ or check out the new manual Resolving OCD by Dr. Frederick Aarmada.
Uncertainty
So to go back and explore the question of why obsessions are so scary in the first place, two possible answers emerge: ERP would say because appraisals and feared consequences, but I-CBT would say because of inferential confusion. Billie Eillish interestingly summed up this distinction in her song Ilo Milo: “The world’s a little blurry, or maybe it’s my eyes”. To follow this analogy, ERP would say to go explore the world and see if your fears are true, whereas I-CBT would say to explore the glasses you’re wearing. There is value in both avenues; a “this or that” answer doesn’t capture the point here. Each complement each other.
Coming Up
In the coming articles, I am going to dive deeper into I-CBT and try to flesh out this new emerging model in a way that is palatable to the general public, and also explore how it could complement and aid ERP work. As always, thanks for your time and attention and see you next week!
References
Aardema, F. (2024). Resolving OCD: Understanding your obsessional experience (Vol. 1). Mount Royal Publishing.
Grayson, Jonathan. Freedom from Obsessive Compulsive Disorder. Penguin Publishing Group. Kindle Edition.
