Inference-based therapy

Inference-based therapy Inference-based therapy is a form of cognitive therapy originally developed in the late 1990’s by Kieron O’Connor and Sophie Robillard for treating obsessive-compulsive disorder. Inference-base therapy highlights the role of inductive reasoning and within this reasoning the role of the imagination in the development of obsessive-compulsive disorder (in particular obsessional doubt). In this model, individuals with obsessive-compulsive disorder are hypothesized to put a greater emphasis on an imagined possibility than on what can be perceived with the senses, and to confuse the imagined possibility with reality (inferential confusion). Inference-based therapy is now applied to anyone of the OCD spectrum disorder and believed to be applicable to other disorders as well. Theoretical model According to inference-based therapy, obsessive-compulsive disorder is a disorder of the imagination rather than perception, where individuals are absorbed in an imagined possibility forming the obsessional doubt (“perhaps my hands are dirty”) at the expense of what can be perceived with the senses in the here and now (“my eyes tell me that hands are clean”). The imagined possibility seems so credible that individual live this possibility as if it were true, and experience physiological reactions, feelings of anxiety, and compulsions that are congruent with the imagined scenario and become immersed in the obsessional doubt. That is, individuals presenting with obsessive-compulsive disorder confuse a possibility with reality and act as if this possibility were true (inferential confusion). In inference-based therapy, the imagined possibility is not a thought that intrudes into the mind, but rather is the result of an internal narrative that leads to 1) a primary inference (the imagined possibility) arrived at following an inductive reasoning style specific to obsessive-compulsive disorder (“perhaps there are germs on my hands”); 2) and secondary inferences, which are the anticipated consequences of the imagined possibility (“if there are germs on my hands, everything I touch will be contaminated, people will get sick, and this will be my fault”). The secondary inferences are logical but sometimes exaggerated sequels to the primary inference. The specific inductive reasoning style is characterized by a distrust of the senses and an overinvestment in remote possibilities. As such, obsessions occur in inappropriate contexts, that is, there is nothing in the here and now that directly justifies the content of the obsessions (germs do exists, but there is no direct evidence that an individual’s hands are contaminated in the here and now). According to inference-based therapy, individuals are more prone to experience specific obsessions in some and not other areas because the content reflects an underlying vulnerable self-theme (e.g., “I might be the type of person who is neglectful”). Inference-based therapy Inference-based therapy is a 20-session manualized treatment delivered in an individual format. The goal of the treatment is to reorient clients towards trusting the senses and relating to reality in a normal, non-effortful way. Differences between normal and obsessional doubts are presented, and clients are encouraged to use their senses and reasoning as they do in non-obsessive-compulsive disorder situations. The exact moment where client cross over from reality to a possibility is identified, and clients are invited to go back to reality, use their senses, and tolerate the void of trusting the senses rather than enacting compulsive behaviors. History Initially, the model was developed mostly for obsessive-compulsive disorder with overt compulsions and for individuals presenting obsessive-compulsive disorder with overvalued ideas (i.e., obsessions with a bizarre content and strongly invested by the individual, such as feeling dirty after seeing a dirty person), given that the model revolves around the imaginative, often idiosyncratic nature of the obsession. The model was expanded to include obsessive-compulsive disorder without overvalued ideas because clinical observations suggested that inferential confusion formed part of the narratives of all types of obsessions (contamination, checking, impulsive phobia, rumination, precision), even if the content of the obsession appeared similar to normal intrusions (“I may have left my stove on”). Finally, the model was further developed to account for obsessions without overt compulsions (which usually revolve around themes such as blasphemy, aggression, or sexuality) by arguing that individuals with obsessive-compulsive disorder could confuse having a thought with thinking of having a thought (e.g., “I will hurt my baby” versus “I could think of hurting my baby”; thought-thought fusion) or could overinvest a sense of self “as it could be” rather than a sense of self “as is” (e.g., dangerous versus not dangerous; fear of self). Thus, the model is now believed to be applicable to all types of obsessions and compulsions. Applications Inference-based therapy was initially developed for obsessive-compulsive disorder, but the treatment has been applied to other disorders where thoughts go against the senses and common sense, such as such as body dysmorphic disorder, hoarding, and eating disorders. The treatment was developed for adults and is being adapted and validated on child and teenager populations. Empirical support As of 2016, over forty empirical papers have been published on inference-based therapy. A literature review on the theoretical background, treatment efficacy, and model of change of inference-based therapy concluded that there is some but limited evidence that obsessions occur in inappropriate contexts. There is good evidence for a specific inductive reasoning style in obsessive-compulsive disorder that may be more sensitive to possibility-based information. There is strong evidence that inferential confusion is associated with obsessive-compulsive disorder symptoms, and good evidence that inference-based therapy is efficacious in treating obsessive-compulsive disorder. In particular, two randomized controlled trials showed that inference-based therapy was as efficacious as cognitive-behaviour therapy for obsessive-compulsive disorder. Limited data suggest that inference-based therapy is more efficacious on some outcomes than cognitive-behaviour therapy for obsessive-compulsive disorder with the most extreme levels of poor insight. There is however limited evidence that the process of change during treatment is coherent with the model’s assumptions. Comparison with cognitive-behavior therapy for obsessive-compulsive disorder Although inference-based therapy is a cognitive model, it differs from cognitive-behavior therapy in several aspects. According to cognitive-behavior therapy, the occurrence of intrusive thought is part of a normal phenomenon, whereas inference-based therapy postulates that the individual is already in the obsessive-compulsive disorder world when the so-called intrusive thoughts occur. According to cognitive-behavior therapy, the source of obsessive-compulsive disorder lies in cognition and faulty appraisals, whereas in inference-base therapy the source of the disorder is in the imagination giving rise to obsessions (obsessional doubt). Inference-based therapy puts the emphasis on processes giving rise to obsessions (that is, inductive reasoning processes sustaining obsessional doubts), while cognitive-behavior therapy focuses on processes following the occurrence of obsessions (the appraisals). In cognitive-behavior therapy, the unit of analysis is an isolated and static thought (e.g., “Having a bad thought is as bad as doing it”), whereas in inference-based therapy the unit of analysis is a narrative, that is, a chain of thoughts that are interrelated in a dynamic way (e.g., “Germs do exist and can get transmitted. We often hear about hand-washing, there must be good reasons for that. I got sick in the past, I could catch something again if I am not cautious”). Clinically speaking, inference-based therapy directly addresses the content of the obsessions, whereas this is counter-indicated in cognitive-behavior therapy (because intrusive thoughts are considered normal). Cognitive-behavior therapy uses cognitive restructuring to produce more realistic appraisals, whereas in inference-based therapy clients are directed to use their senses in the here and now and act accordingly. Exposure and response prevention is not a central technique used in inference-based therapy, while it is a core intervention in cognitive-behavior therapy. Inference-based therapy refers to “reality sensing” where the person connects with reality through practice rather than exposure to facilitate inhibition of compulsions or habituation to anxiety. The connecting with reality is distinct from mindfulness exercise of being fully present in the here and now and focusing on the five senses whilst letting thoughts go by since the person is encouraged to connect normally with reality and let reality appear automatically without specific effort when imagination is not in the way. The person can also appeal to the common sense which is usually non-OCD and grounded in reality. However, use of techniques in inference-based therapy requires thorough training and understanding of procedures and a client-centered evaluation. Despite differences between inference-based therapy and cognitive-behavior therapy, the two models are not incompatible. In fact, inference-based therapy and cognitive-behavior therapy may complement each other given the two models focus on different aspects of the sequence leading to obsessive-compulsive disorder. A treatment combining inference-based therapy and cognitive-behavior therapy has been developed and showed promising results. Website: tictactoc.org For a complete list of zip file, please contact Kiron O’Connor, Phone: +514-251-4015 ext. 2343; email: [email protected].