OCD, Shame and the Schizoid Process: A Useful Clinical Map

Exposure and Response Prevention, or ERP, is one of the most important and best-supported treatments for obsessive-compulsive disorder.

I use ERP extensively in my work as an OCD specialist in London.

At the same time, after many years of clinical practice, I have become increasingly interested in what sits around the obsessive-compulsive cycle: particularly self-criticism, shame, excessive responsibility, withdrawal and the tendency to become trapped inside one's own internal world.

One framework I find useful for understanding these processes comes from psychotherapist Richard Erskine's work on the schizoid process.

This does not mean that people with OCD have schizoid personality disorder.

Nor am I suggesting that the schizoid process, childhood criticism or trauma causes OCD. We still do not know exactly why one person develops OCD and another does not.

I find Erskine's model valuable for a different reason.

It can provide a clinical map of psychological processes that may become intertwined with OCD, regardless of where the OCD originally came from.

The schizoid process is not schizoid personality disorder

The term can understandably cause confusion.

Erskine uses the idea of the schizoid process to describe ways in which aspects of a person's experience become separated from one another in response to relational pressure, criticism, shame or vulnerability.

His published model describes four forms of splitting.

For OCD treatment, I find the second, third and fourth particularly relevant.

The first split: the Social Self

Erskine describes a distinction between what he calls the Vital and Vulnerable Self and the Social Self.

A child naturally has needs, feelings, anger, vulnerability, spontaneity and preferences.

Where those repeatedly meet criticism, unrealistic expectations or emotional misattunement, the child may learn to present a version of themselves that is more acceptable to other people.

The underlying rule can become:

I need to be what other people require me to be.

This is not an explanation of OCD.

But if OCD later develops, this pattern may become clinically relevant where we see excessive responsibility, perfectionism, fear of disappointing others or difficulty trusting one's own experience.

The second split: when criticism becomes internal

Erskine's second split involves Introjected Others.

The standards and attitudes of significant people become internalised.

The person may no longer require someone standing beside them saying:

You should have known better.

Don't make a mistake.

What will people think?

You should not feel that way.

Eventually those messages can come from inside.

This is particularly interesting in forms of OCD involving responsibility and scrupulosity.

A person may carry a powerful internal expectation that they should have anticipated every possible consequence, behaved perfectly or prevented anything bad from occurring.

The third split: when the person's own critic becomes even harsher

Erskine's third split goes further.

He describes the development of an Internal Saboteur, or sometimes an Internal Strategist.

The person is no longer merely replaying past criticism.

They have developed their own system of self-monitoring and self-attack, which may become more relentless than the criticism they originally encountered.

Its intention may originally have been protective:

If I criticise myself before anyone else does, perhaps I can prevent humiliation.

If I continually monitor myself, perhaps I will not make the mistake.

If I work out what is wrong with me, perhaps I can fix it.

But what was intended to provide protection can eventually become a source of suffering.

And this is where the parallel with OCD becomes especially powerful.

“What if this says something terrible about me?”

Consider responsibility OCD or moral scrupulosity.

Something happens.

Perhaps someone becomes upset.

Perhaps the person remembers something they said years ago.

Perhaps an intrusive thought or image appears.

Perhaps they suddenly realise that they could theoretically have prevented something bad.

The question quickly shifts from:

What happened?

to:

What does this say about me?

Was it my fault?

Why did I think that?

What if I am selfish, immoral, dangerous or irresponsible?

The person may replay conversations, inspect their motives, review memories, confess, apologise, research, seek reassurance or reconstruct events repeatedly.

They are trying to find certainty.

But underneath the anxiety there can be something even more painful:

shame.

Not simply:

Perhaps I made a mistake.

But:

There must be something wrong with me.

That distinction matters.

Guilt concerns something we believe we have done.

Shame tends to concern what we believe we are.

This is not merely a clinical impression. A 2023 systematic review and meta-analysis found a meaningful positive association between shame and obsessive-compulsive symptoms, with shame also linked to avoidance, social withdrawal and reluctance to disclose symptoms.

That matters particularly in OCD involving taboo, sexual, aggressive, religious or morally unacceptable intrusive thoughts. The person may not only fear that others will misunderstand the thought. They may already have interpreted the existence of the thought as evidence against their own character.

The compulsion can then become more than an attempt to reduce anxiety.

It can become an attempt to restore a threatened sense of self.

If I can prove that I did not mean it, perhaps I am still a good person.

If I can establish that I did everything possible, perhaps I am not irresponsible.

If I can reach certainty, perhaps I can stop accusing myself.

This is where I find Erskine's second and third splits especially useful in understanding OCD and shame.

They do not tell us where the OCD came from.

They help us understand what the OCD may have become entangled with.

The fourth split: withdrawal into the internal world

Erskine's fourth split is the Sequestered Self.

When external criticism, internalised criticism and self-attack become overwhelming, withdrawal can become a form of protection.

The person retreats inward.

There is an obvious parallel here with some forms of OCD.

Many compulsions are visible: washing, checking doors, repeating movements or arranging things.

But a great deal of OCD happens almost completely internally.

Someone may be sitting beside their partner while spending twenty minutes mentally reviewing a conversation.

They may be examining whether they really meant something.

They may be analysing an intrusive thought.

They may test their feelings or memories.

They may try repeatedly to determine whether they are sufficiently certain.

From the outside almost nothing is happening.

Inside, most of the person's attention has withdrawn from ordinary life and become absorbed in an internal system of monitoring, analysing and judging.

This does not mean that a mental compulsion is a schizoid process.

Rather, the two processes may reinforce one another.

Shame encourages secrecy.

Secrecy encourages withdrawal.

Withdrawal allows internal monitoring to dominate.

And the person's world becomes increasingly organised around a private attempt to resolve something that can never finally be resolved.

There is supporting evidence for this part of the picture as well. Shame and embarrassment are recognised barriers to disclosure and treatment-seeking in OCD, and concealment is particularly common where obsessions involve themes the person finds morally threatening or humiliating.

A possible cycle

For some people with OCD, the process may resemble:

criticism or excessive responsibility → internalised standards → self-criticism → shame and anxiety → withdrawal into internal monitoring → compulsive attempts to resolve uncertainty → temporary relief → greater dependence on the cycle.

This is not a universal model of OCD.

It is a clinical formulation that I find particularly useful in responsibility OCD, scrupulosity, perfectionistic presentations, taboo intrusive thoughts and cases involving intense self-judgement.

It also helps explain why somebody may intellectually understand their OCD extremely well and still become overwhelmed by it.

They may know that the ritual will not create permanent certainty.

But the ritual is not operating only at the level of logic.

It is embedded in an emotional system involving threat, shame and self-protection.

The overlap with depression, addiction and self-harm

Depression, addiction, self-harm and OCD are very different conditions.

They should not be reduced to one explanation.

However, they can sometimes share psychological processes such as:

self-criticism, shame, withdrawal, loss of connection and attempts to escape an intolerable internal state.

The link between shame and depression is particularly well established, with meta-analytic research showing a substantial association between shame and depressive symptoms.

Self-criticism has also been associated with self-harm, while addiction research has long examined the role of negative reinforcement — the use of a substance or behaviour to reduce an unpleasant internal state.

OCD is not classified as a behavioural addiction, but there is useful overlap at the level of compulsivity and negative reinforcement. The compulsion produces short-term relief from uncertainty, anxiety, guilt, disgust or shame, which can strengthen the probability of repeating it.

This addiction-like lens is something I was introduced to through my energy psychology mentor, Mary Sise, and I continue to find it clinically useful.

The outcomes are different.

But some of the underlying human strategies overlap.

A treatment map rather than an origin story

This distinction is important.

A developmental or trauma-informed framework can be clinically useful without claiming that trauma caused the OCD.

We can work backwards from the process occurring now.

If somebody's OCD is intertwined with severe shame and self-criticism, then shame and self-criticism are reasonable therapeutic targets regardless of where the OCD originally came from.

If they disappear into hours of mental ritualising and withdraw from relationships, we can work with withdrawal and reconnection.

If their internal world is dominated by harsh standards and self-attack, we can work on developing a different relationship with the self.

This is how I use Erskine's model.

Not as a theory explaining the origins of OCD.

As a map that can help us recognise important processes surrounding it.

ERP remains essential — but sometimes the map needs to be wider

ERP remains a central part of evidence-based OCD treatment.

But my clinical experience is that some people, particularly those with more complex or longstanding OCD, benefit from treatment that also addresses the psychological processes with which their OCD has become intertwined.

There is also growing evidence that self-compassion is relevant here. A 2026 systematic review and meta-analysis found that lower self-compassion was associated with greater obsessive-compulsive symptom severity, with particularly strong associations around unacceptable thoughts.

That does not prove that compassion-focused work should be part of every OCD treatment.

But it does support the clinical relevance of asking not only:

How do we help this person resist compulsions?

but also:

How do we help them stop relating to themselves through relentless self-attack?

This is part of the rationale behind the RIOT Method I use in my work: combining ERP and cognitive approaches with appropriate psychotherapy, mindfulness, self-compassion and somatic methods.

The aim is not simply to reduce rituals.

It is to help the person develop more freedom, more connection, greater tolerance of uncertainty and a less punitive relationship with themselves.

Richard Erskine's model of the schizoid process does not explain everything about OCD.

But for some people, it can illuminate something very important:

how internalised criticism becomes self-attack, how self-attack generates shame, and how shame can drive the person further inside themselves.

Once that pattern becomes visible, treatment can become considerably more precise.

References

Erskine, R. G. (2022). Relational Withdrawal, Internal Criticism, Social Façade: Psychotherapy of the Schizoid Process. International Journal of Psychotherapy, 26(1), 75–93.

Erskine, R. G., et al. (2023). Withdrawal, Silence, Loneliness: Psychotherapy of the Schizoid Process. Phoenix Publishing House.

Laving, M., Foroni, F., Ferrari, M., Turner, C., & Yap, K. (2023). The association between OCD and shame: A systematic review and meta-analysis. British Journal of Clinical Psychology, 62(1), 28–52.

Shnayder, S., et al. (2026). The association between obsessive-compulsive symptoms and self-compassion: A meta-analysis and systematic review. Journal of Affective Disorders.

Petrocchi, N., et al. (2021). Compassion-Focused Group Therapy for Treatment-Resistant OCD: Initial Evaluation Using a Multiple Baseline Design. Frontiers in Psychology.

National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31).