The OCD Whisperer Podcast with Kristina Orlova

Episode 132: Cognitive Therapy for OCD

Date: April 1, 2025
Guest: Mike Parker, LCSW (OCD Space)

Episode Overview

In this episode, host Kristina Orlova sits down with licensed clinical social worker Mike Parker to demystify Inference-Based Cognitive Behavioral Therapy (ICBT) as a leading treatment for OCD. Together, they explore the core differences between ICBT and traditional approaches like ERP, discuss the concept of obsessional doubt, and share personal insights into how reasoning errors fuel OCD symptoms. Parker provides clear examples, practical tips, and highlights ICBT’s effectiveness for those struggling to trust themselves or escape persistent loops of doubt.

Key Discussion Points & Insights

1. What is ICBT and How Is It Different?

• ICBT Defined:
  ICBT (Inference-Based Cognitive Behavioral Therapy) is identified as a fundamentally different “recipe” from ERP (Exposure and Response Prevention) or standard CBT.
  • “If you make it right, it'll taste exactly the same, but you can't mix them.” [02:00, Mike Parker]
• Core Focus:
  Unlike ERP, which labels reassurance seeking as a compulsion to be stopped, ICBT asks: Why are you asking for reassurance?
  • Emphasizes understanding the “obsessional doubt” process that drives OCD.

2. Obsessional Doubt: The Heart of OCD (ICBT Perspective)

• How doubt manifests:
  • People with OCD receive reality-based information but habitually reject or question it, creating a cycle of doubt disconnected from actual evidence.
• Example given:
  • When someone seeks reassurance, ICBT explores why they doubt their knowledge, aiming to help them answer their own questions by understanding their thought process.
  • “Obsessional doubt is essential to ICBT...It’s the idea that someone with OCD knows something, but they don’t really trust themselves enough to stick with what they know.” [02:00, Mike Parker]
• ICBT’s goal:
  • Help clients notice when they disregard valid information and why, in order to break the compulsion loop at its cognitive root.

3. Reasoning Errors and Internal Evidence

• Reliance on Internal Evidence:
  • Many with OCD use feelings, sensations, or mere doubt as “evidence” something is wrong, leading to self-fulfilling cycles.
  • “Someone may think that a sensation in their body is reason to go into obsessional doubt.” [09:26, Mike Parker]
• “Blank Slate” Problem:
  • People with OCD may ignore ample evidence about themselves, replacing real self-knowledge with “what ifs” and out-of-context stories (e.g., identifying with a news story about a criminal and thinking, “What if that’s me?”).
  • “If someone has harm OCD...they’ll say, ‘What if that is me?’...That person has nothing to do with who you are.” [11:11, Mike Parker]

4. Contextualizing Facts and OCD Reasoning

• Out-of-Context Reasoning:
  • OCD often fixates on general facts instead of context (“germs exist” ➔ “I must worry about every contact”).
  • “You’re very much drawn to thinking about possibilities, and then you end up thinking about general facts—not facts that are necessarily relevant to you in the moment.” [13:31, Mike Parker]
• ICBT Intervention:
  • Teaches clients to focus on present-moment, reality-based information rather than generalized or tangential fears.

5. Addressing Real Mistakes and Trust

• When feared events actually occur:
  • People with OCD usually cope well if their fear becomes reality—contrary to their expectations.
  • “When the thing they’re concerned about actually happens, they’re typically able to deal with it, like, no problem. And I’m always amazed by that.” [14:49, Mike Parker]
• Distress Root Cause:
  • The true agony is not the feared event, but the persistent inability to trust what one already knows.

6. Childhood Roots and Life Messaging

• Exploring the origins:
  • ICBT can incorporate exploration of early influences—family messages, personal experiences, or cultural factors—that helped form present OC reasoning.
  • Unlike prior CBT doctrine which discouraged examining the “why,” ICBT finds therapeutic value in tracing the roots of obsessional stories to help clients reframe and detach from them.
  • “We can start to see how long the client has been telling themselves an obsessional story about themselves…” [17:47, Mike Parker]

7. Psychodynamics vs. ICBT

• Clear boundaries:
  • ICBT isn’t psychodynamic therapy:
    • Psychodynamic models (focus on unconscious drives) can be misused or misinterpreted by OCD brains.
    • ICBT is a cognitive therapy, focusing on reasoning processes—why people accept or reject information, not hidden motives.
    • “The main reason to stay away from psychodynamic therapy is…it is founded…on an idea of an unconscious…which is…like…not helpful for a lot of people [with OCD].” [20:54, Mike Parker]

8. How ICBT Facilitates Change

• Reasoning leads to behavior change:
  • By recognizing how and when reasoning becomes distorted, clients begin to act differently—without explicit behavioral assignments.
  • “Once you understand that really the distorted reasoning processes…then you'll start to essentially behave differently.” [22:32, Kristina Orlova]
• ICBT as primarily a cognitive therapy:
  • Traditional CBT’s focus on assessing probability doesn’t address the obsessional doubt; ICBT shifts to the “why” behind the doubt itself.

9. Duration and What to Expect

• Timeline:
  • Progress ranges from 3 months to a year, depending on complexities (e.g., trauma, perfectionism, disgust sensitivity).
  • “The longest client I’ve had…was about a year…[but] I’ve probably had clients that are really doing well after like three months or so…” [27:18, Mike Parker]
• Complicating Factors:
  • Trauma, loss, perfectionism, or shame may extend therapy, but “pure OCD” often responds more quickly.

Notable Quotes & Memorable Moments

• The “Recipe” Analogy:

  • “It is like that with ICBT. It's like you kind of have to learn, you have to get absorbed in a completely new recipe and use those tools and stick with that for a little while and see how it goes.” [02:00, Mike Parker]

• Obsessional Doubt Explained:

  • “What we're going to find is when someone who has been doing a different treatment encounters obsessional doubt or the word, they're not really going to know what to do with that. They're going to say, oh, is that a compulsion? Is that a obsession? Is that an intrusive thought? What is that? And what I have found is it is none of the above.” [02:32, Mike Parker]

• On the “Blank Slate” Problem:

  • “When you are a blank slate, lots of things can suddenly seem like they apply to you.” [11:14, Mike Parker]

• Difference from Psychodynamics:

  • “Freud wasn't saying that you could secretly be a serial killer even though you've, like, never hurt someone before. There's no way that was the point…But OCD will take it that way.” [21:22, Mike Parker]

• Automaticity of Doubt:

  • “Because it's been so long, it's like anything in life, it becomes an automatic kind of habitual way…” [25:37, Kristina Orlova]

Important Timestamps

• [02:00] — ICBT as a whole new “recipe”; obsessional doubt explained
• [09:26] — Internal evidence and reasoning errors in OCD
• [13:31] — General facts versus context in OCD thinking
• [14:49] — People with OCD cope when feared events actually happen
• [17:47] — Validating early influences and childhood messaging
• [20:54] — ICBT vs. psychodynamic approaches
• [22:32] — The cognitive focus and change process in ICBT
• [27:18] — Expected therapy timelines and complicating factors

Resources & How to Connect

• Mike Parker, LCSW:
  • YouTube: OCD Space
  • Therapists: ICBT training at icbttrainingonline.com
  • Website: Mike Parker LCSW

This episode offers a clear, hopeful, and nuanced exploration of ICBT for OCD, making it a valuable listen for those seeking practical understanding and real-world strategies—whether you’re new to ICBT, a clinician, or someone living with OCD.