The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Inference-based CBT is a focused form of cognitive therapy that is grounded in an inference-based approach (IBA) to treating OCD. This approach focuses on the role of reasoning in the development and maintenance of OCD. It identifies that unhelpful reasoning processes lead to the initial inference of doubt and deflect attention from obvious realities. Inference-based CBT therefore aims to help patients identify and reject reasoning processes that prevent the use of sensory information. In turn, patients are able to rely on present sensory information to maintain contact with reality; protect themselves from the misleading and consuming effects of obsessive reasoning; recognise the superfluities in compulsive acts; and prevent engagement in these acts.
Inference-based CBT is an individually delivered, manualised intervention. It is typically offered weekly, over 20 sessions, each session lasting about 45 minutes. Inference-based CBT sessions include the delivery of 10 modules, with the goal of reorienting patients to reality. The core focus of each of these modules includes:
- Module 1: Differentiating between normal doubt (that is triggered by concrete, present sensory information) and obsessional doubt
- Module 2: Enhancing patient awareness of the reasoning processes that maintain obsessional doubt
- Module 3: Highlighting that obsessional doubt is not supported by available evidence that is perceived by the senses
- Module 4: Identifying the narrative resulting in observational doubt, and creating a realistic, alternative narrative that is based on here and now sensory information
- Module 5: Identifying the point of inferential confusion, i.e. crossing over from reality to possibility
- Modules 6 and 7: Highlighting the role of inductive reasoning devices in the creation of obsessional doubt
- Module 8 and 9: Illustrating the selective nature of obsessional doubt, achieved by exploring situations in which doubt is absent, and identifying personal themes that are associated with obsessional doubt.
- Module 10: Supporting patients with trusting their senses
Delivery of these modules are expected to prevent the development of obsessional doubts (i.e., primary inferences), and the series of secondary inferences (i.e., anticipated consequences), anxieties and compulsions that follow from the primary inferences.
Fidelity
Practitioners delivering Inference-based CBT should receive training that addresses Inference-based CBT delivery, adherence to treatment protocol, and the use of supporting materials (e.g., forms for exercises and homework assignments). The intervention should be delivered as specified in session-by-session protocol. Practitioner competence and fidelity to treatment can be monitored and evaluated using appropriate measures, e.g., via recording and reviewing treatment sessions to determine practitioner adherence to Inference-based CBT protocol. The CTS-R can be used as part of this assessment (Blackburn et al. 2001), supplemented by review of adherence to the session protocol.
Modifiable Components
Inference-based CBT can be delivered alone, or as an integrated therapy in combination with standard CBT. In addition to face-to-face delivery, Inference-based CBT can be delivered remotely using videoconferencing tools. Inference-based CBT can be delivered in clinical and non-clinical settings. A self-guided version of Inference-based CBT has been evaluated.
Supports - Rating: 4
4 - Supported
Some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention
Support for Organisation / Practice
Implementation Support
The Inference-based CBT clinician handbook for OCD provides a clinician guide for the application of inference- based therapy (IBT) as it relates to the treatment of OCD. There is also support online with resources, materials, guidelines, instructions, trainings and professional groups supporting other professionals (see www.icbt.online).
Services will need to fund and access training, support and supervision.
Start-up Costs
Training is available via https://icbt.online/find-treatment/
Costs apply when training is provided by private organisations.
Building Staff Competency
Qualifications Required
Staff will usually hold an undergraduate degree in a relevant area (e.g., nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).
Training Requirements
Training is available through the icbt.online website where there are a range of training providers listed. Most are based outwith the UK: Consultation and Training – Inference-based Cognitive Behavorial Therapy (icbt.online)
Training includes individual and group consultations to support the application of Inference-based CBT in practice.
Supervision Requirements
Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:
- NES Generic supervision competences training (GSC) (or equivalent)
- NES Specialist Supervision Training: CBT (adult or child focus)
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: Supervision of psychological therapies and intervention | NHS Ed (scot.nhs.uk). There is additional training available that specifically supports CBT supervision skills.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
Reasoning and cognitive theory underpins the inference-based approach (IBA) and the therapy programme (Inference-based CBT) that is derived from it. IBA recognises OCD as a reasoning disorder that causes confusion of possibilities with reality (inferential confusion). This results in obsessional doubts (i.e. the primary inferences) and a series of secondary inferences (i.e. anticipated consequences), anxieties and compulsions that follow from the primary inferences. The Inference-based CBT therefore targets the initial obsessional doubts and the reasoning processes that underpin this doubt. This is expected to help patients maintain contact with reality, protect themselves from the effects of obsessive reasoning, and recognise the superfluities in compulsive acts.
Research Design & Number of Studies
There are more than 80 published empirical studies relating to the inference-based approach (IBA), including a number of trials focused on mechanisms of change, as well as one open trial and three randomized controlled trials.
One study was an RCT which compared IBA to CAM and ERP (1). The study included 54 participants who were randomly allocated to IBA, to a treatment based on the cognitive appraisal model (CAM), or to exposure and response prevention (ERP). Participants had a primary diagnosis of OCD, with overt compulsions for at least 1-hour daily. IBA was delivered over 20 weeks in weekly sessions.
Another comparative RCT evaluated the effectiveness of IBA and CBT in OCD management. The study included 90 adult participants, who were diagnosed with poor insight OCD, and who were assigned to receive either 24 CBT sessions or 24 IBA sessions. In both conditions symptom reduction was reached. In a small sub-group of patients (24) it was found that patients treated with IBA reached significantly higher OCD symptom burden than the patients treated with CBT (2).
Another study was an open trial that evaluated an inference-based approach (IBA) for the treatment of OCD across symptom subtypes and treatment-resistant cases. The study included 125 OCD participants aged 18-65 years with a primary OCD diagnosis. 20 individual Inference –based CBT treatment sessions were delivered over the 24-week treatment programme by trained psychologists. The comparison group was a wait-list control group that consisted of 22 participants. The treatment is equally effective for those with high and low levels of overvalued ideation. Treatment based on the inference-based approach may be particularly valuable for those who have shown an attenuated response to cognitive behavior therapy as usual (3).
The fourth trial was a RCT comparing I-CBT and A-CBT. MBSR intervention acted as a non-specific control condition. All treatments significantly reduced general OCD severity without a significant difference between treatments (4).
Adult Outcomes Achieved
Compared to CBT or wait-list control, the following outcomes were observed;
- Significantly reduced OCD symptoms at post-treatment (2-4). Improvements in symptoms were maintained at 6-months follow-up (3).
- Significantly greater reduction in OCD symptoms in subgroup of patients with the worst insight at post-treatment (2).
- Significantly reduced depression and anxiety symptoms at post-treatment (3).
Need
Comparable Population
Inference-based CBT has been shown to be effective in the treatment of OCD, across symptom subtypes, in all levels of severity, and in patients with poor insight.
Desired Outcome
Inference-based CBT is associated with significant improvements across several outcomes including OCD, depression, and anxiety.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Inference-based is a focused form of cognitive therapy that is grounded on an inference-based approach (IBA) to treating OCD. Reasoning and cognitive theory underpins the inference-based approach (IBA) and the therapy programme (Inference-based CBT) that is derived from it. Inference-based CBT therefore focuses on the role of reasoning in the development and maintenance of OCD.
Priorities
Inference-based CBT helps patients to target initial obsessional doubts and the reasoning processes that underpin this doubt. This is expected to help patients maintain contact with reality, protect themselves from the effects of obsessive reasoning, and recognise the superfluities in compulsive acts. Inference –based CBT can be delivered alone, or as an integrated therapy in combination with CBT. It can be delivered face-to-face or remotely, in clinical and non-clinical settings.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Inference-based CBT can be delivered by healthcare professionals (e.g. psychologists, psychiatrists, or mental health nurses) who have undergone training to support its delivery. Inference-based CBT can be delivered to patients weekly, typically over 20 sessions.
Technology Support
Inference-based CBT can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.
Administrative Support
Inference-based CBT is an individually delivered, manualised intervention. It is typically offered weekly, over
20 sessions, each session lasting about 45-minutes. Inference-based CBT can be delivered remotely or in-person. In-person delivery can be held in clinical and non-clinical settings. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
