Moritz & Jelinek: Association splitting

Association Splitting
Self-Help Guide for Reducing Obsessive Thoughts

Steffen Moritz
Lena Jelinek

Contact:
Steffen Moritz, Ph.D.
Department for Psychiatry and Psychotherapy
University Medical Center Hamburg-Eppendorf (UKE)
Martinistr. 52; 20246 Hamburg, Germany
Status: 12.05.2022

Translation from the German by Jana Volkert

VanHam Campus Press

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 Moritz & Jelinek: Association splitting

Foreword
This manual would not have been possible without the support of many people. First, we
would like to express our gratitude to all our colleagues for their help during the development
of this manual. In particular, we would like to thank Birgit Hottenrott and Ruth Veckenstedt
for their critical review of this manual and the implementation of an efficiency study on the
Internet. We are also indebted to Jana Volkert for a preliminary translation of the manual,
which was burdened by the fact that many of the original German examples do not work in
other languages. Special thanks go to the translator Kenneth Kronenberg who edited the
manual and suggested several new examples (http://www.kfkronenberg.com). Finally, we
would like to thank participants in a pilot study, whose feedback, especially on
comprehensibility and daily application of the technique, has led to significant improvement.
We would be very grateful to receive feedback about your experiences with this method at
[email protected]. Suggestions for improvements, and criticism, are as welcome as
plaudits.

Request for donations and funding

Considering the difficult financial situation of many people suffering from obsessive-
compulsive disorder (OCD), we will continue to offer this manual and other self-developed
treatment programs free of charge (see for example our metacognitive training program for
schizophrenia patients at http://www.uke.de/mkt).

However, research is expensive and in times of scarce public funding it is not only time-
consuming, but also requires private funding. If you would like to support us in providing
cost-free treatment methods, we would be grateful for donations. Irrespective of individual
support, we will attend to all inquiries and offer support on individual applications of the
technique. No one should feel morally obliged to donate! Donations will be used for research
purposes only (upcoming projects include translation into Spanish, improved examples,
payment of research interns). If needed for tax purposes, we will be happy to send you a
receipt.

Account holder: Universitaetsklinikum Hamburg-Eppendorf

Bank: Hamburger Sparkasse (bank identification number: 200 505 50)
Account#: 1234 363636
Reference/Reason for Payment line (this is crucial to ensure that
your donation reaches us): 0470/001-OCD
IBAN: DE54200505501234363636
BIC/Swift: HASPDEHHXXX

Thank you and best wishes!

Steffen Moritz & Lena Jelinek

Cover image: Association splitting: Bernd Hampel, inspired by an El Lissitsky painting titled
“Beat the Whites with the Red Wedge.”

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 Moritz & Jelinek: Association splitting

Dear patients, relatives, and colleagues,

Our research group has been involved in the research and treatment of obsessive-compulsive
disorder (OCD) for many years. Since the end of 2005, we have been developing a new
treatment method (association splitting), which aims at reducing the intensity and frequency
of obsessive thoughts. In the following chapters, we invite you to try this method for yourself.

Although we regard our approach as very promising, we would like to warn against overly
high expectations. In a pilot study with 30 OCD patients, we found an average reduction in
obsessive-compulsive symptoms of 26%; the intensity of obsessive thoughts was reduced by
25%. After three weeks, during which the method was self-administered, up to 42% of
participants showed a decline in symptoms of at least 35%. Association splitting therefore
represents a promising treatment strategy for a subgroup of patients. We have further refined
the approach since our pilot study. In the future, we will especially focus on having our
method incorporated into existing therapy programs.

1. To whom this manual is addressed...

The method is aimed at people who suffer from specific, that is, concrete obsessive thoughts
(e.g., excessive concern with contaminating others; uncertainty about having run over a
pedestrian; fear of causing a catastrophe by failure to place things in a particular order, or not
saying a certain prayer).

Currently, the method may not be of benefit to the following individuals:

a. Individuals who perform compulsive actions exclusively, that is, without awareness of
preceding obsessive thoughts. Compulsive actions may include excessive washing of one’s
own body, checking (e.g., oven, door lock), sorting, and excessive hoarding. There are also
mental compulsive actions such as counting or mental rituals, which are employed to
“prevent” obsessive thoughts or their feared consequences. In most cases obsessive
thoughts precede compulsive actions (e.g., exaggerated fear of having been contaminated
[obsessive thought] is followed by a washing ritual [compulsive action]).
b. Individuals, who do not at least partially acknowledge the absurdity or exaggerative
nature of their thoughts. Individuals who are convinced that their thoughts, concerns, and
actions are entirely justified and rational, are not likely to benefit from the method.

If you experience no positive effects from association splitting, please do not give up hope.
There are other effective therapy options for OCD, especially cognitive-behavioral
techniques. Consult a clinician who specializes in OCD, or a self-help organization.

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2. Associations
Our approach is based on findings from cognitive psychology. The technique is intended to
weaken associations connected with agonizing thoughts. Such thoughts, also called
obsessions, may culminate in panic and catastrophic ideas and often result in compulsive
rituals such as excessive washing and checking. Before we turn to the treatment method itself,
it is necessary to explain briefly the mechanisms underlying associative networks. Our
explanation here will be somewhat oversimplified, but the interested readers are urged to
consult Manfred Spitzer's The Mind Within the Net: Models of Learning, Thinking, and Acting
(Bradford Books, 1999), which, in a very illustrative and straightforward manner, summarizes
current scientific knowledge about thinking and its representation in the brain. We ask you
not to skip this introductory section, because the efficacy of this method relies on a clear
understanding of its core underlying principles.

Central to our approach are associations, that is, connections between thought contents (from
now on these will be referred to as cognitions). Cognitions may include memories, words,
emotions, or action impulses. In the following, the virtually identical term thought will be
used only to refer to linguistic contents (i.e., words or sentences).

Brain research suggests that cognitions are embedded in the brain as cell assemblies (neuron
networks), mainly in the frontal and temporal lobes of the brain. At the brain level, the
strength of the connection between two thoughts equals the transmission strength of specific
messengers, called neurotransmitters, between neurons. Neurotransmitters function like
lubricants between cells, ensuring improved communication from cell to cell (there are also
inhibitory messengers, which will not be discussed further in this context.)

pear sunset
heat apple

cherry
transport street fire sunrise

fire red
car rose
department cloud

bus orange
ambulance yellow
violet
truck
green flower

Figure 1: The diagram shows a network of thought associations. Cognitions are connected in the brain by their
meaning or sound. The more frequently concepts are used together or in the same context, the more strongly they
are connected

Figure 1 shows an associative network, which comprises, amongst other things, different
types of fruit, whose associations also extend to other networks (e.g., colors). For clarity we
have only depicted a few connections. Other cognitions and associations (e.g., between apple
and green) are, of course, also possible.

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Communication within the semantic network is achieved with the help of association
spreading, that is, one cognition activates another and so on. For example, when we rehearse
and recite a poem, we practice (i.e., strengthen) specific associations, which in the beginning
were perhaps only weakly connected (e.g., the rhyme house with mouse). Cell connections are
strengthened by the process of rehearsal. Later on, when reciting a key word the next word is
basically warmed up and on the tip of the tongue. The following principles are relevant for a
deeper understanding of the mechanisms behind associations:

a. Associations are based on learning and largely depend on experience: Although

some associations have been deeply imprinted in the human brain as a result of
evolutionary processes over the millennia, and therefore do not require specific
individual learning,1 most mental connections depend on learning and experience. For
example, over the course of our life we learn to stop for red traffic lights (association of
a visual stimulus with a specific reaction), that a robin is a bird (connection of a
picture/word with a superordinate term), table in French is called la table (connection of
a word with another word), or that it is a bad idea to touch a hot stove (connection of a
tactile stimulus with a visual and pain stimulus). Associations develop automatically
when thoughts appear together more frequently (e.g., the color black when looking at a
cup of coffee). At the beginning, our memory is more or less empty—a blank slate—
with the exception of the aforementioned “collectively acquired” information. Because
many humans share a similar repertoire of experiences or have grown up in a
comparable cultural milieu, people tend to produce very similar associations. Studies in
which people are asked spontaneously to associate words that pop into mind when
presented with a certain cue word demonstrate that most people associate the word
black with the word white, or hammer with the word nail. Also, many people United
States will associate the word president with the names Obama, Bush, or Clinton. Still,
numerous individual differences exist owing to the specific learning environment of a
person. A soccer fan is more likely to associate the word ball with goal rather than
dancing, while a professional dancer will probably have the opposite association.

Persons with OCD often have idiosyncratic and, at the same time, very lopsided
associations. A person excessively fearful of murdering his or her children with a knife
will, when seeing a knife, more likely to associate it with those obsessive concerns or
experience visions of horror, rather than have a neutral cognition like spoon, fork, or
cutting up vegetables for cooking. OCD patients also have such neutral associations, but
they are buried and/or their intensity is much weaker.

b. Thoughts are controllable… and yet not: Thoughts come and go. Experimental
studies show that most of our thoughts vanish within a few hundred milliseconds.
However, during this time new thoughts are activated and spread like falling dominos.
This happens automatically—irrespective whether we want it or not.

1
When we come face-to-face with a snake or other object that has been associated with danger since time
immemorial and has become virtually hard-wired, an unconscious flight response is transmitted via the neuron
cell connections of the visual center to a brain area called amygdala. These connections function without prior
individual experience.

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We will briefly demonstrate the principle of association spreading with a short exercise.
Please answer the following four questions as quickly as possible:

a. What is the color of a polar bear? - [white]!

b. What is the color of a snowflake? - [white]!
c. What is the color of a lab coat? - [white]!
d. What does a cow drink? ...

Most people who take part in this little experiment spontaneously answer the last
question with milk, although water is the correct answer. If however, you ask the final
question without the three preceding ones, most people will produce the correct answer.
This phenomenon is based on the fact that thought contents that are associated with
white (including milk) are facilitated or warmed up, so that they are closer to
consciousness and are on the tip of the tongue. Asking the question, “What does a cow
drink?” unconsciously leads to milk as it is already co-activated by white and has
gained further activation by the word cow (as most people also associate cow with
milk), thus prompting the wrong answer.

Figure 2: Asking people the color

of a polar bear, a snowflake, and a
polar bear snowflake lab coat (green boxes), activates
the word white (red box).
Consequently, other concepts
related to white are automatically
white lab coat
co-activated (orange boxes). If the
question “What does a cow
cow drink?“ is then asked, many
people spontaneously answer milk
sheet of paper although they know that cows
milk flour drink water. Milk however is on
the tip of the tongue (pre-
activated) by the influence of the
explicitly stated in the question two concepts white and cow.
highly activated
pre-activated

Total control over the flow of thoughts is neither sensible nor possible! When we
speak, we may to some extent be able to direct our talk to a certain point (e.g., prepare
some words we would like to use in advance). But it is almost impossible to plan the
exact wording and intonation beforehand. Pre-conscious processes, in the form of
strong association assemblies, navigate our thinking. These association assemblies
(e.g., verb and object follow the subject) do not come out of the blue nor are they
innate, but, again, reflect our particular learning history. In part, we learn these with
great effort at school (e.g., to raise our voice at the end of a question; to say “I
brought” rather than “I bringed” etc.). This knowledge increasingly becomes second
nature to the point where we do not need to think in order to make use of it.

Other examples where thoughts are not fully controllable

Positive: sudden inspirations or ideas; spontaneous jokes; using a foreign word
without being aware of having known the word before
Negative: mental black-outs during exams

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Normal: slips of the tongue (e.g., “Thanks for your hostility” instead of “Thanks for
your hospitality”). The more we try to control our cognitions, the more easily such
errors occur.
Thoughts evaporate within a few seconds if we make no effort to hold onto them. Yet
we also experience the phenomenon—and not only in the case of obsessive thoughts—
of being unable to let go of thoughts, of being almost haunted by them. Who has not at
some time tried—in vain—to get an annoying tune out of his head? Or what about pre-
exam jitters? Most people experience such intrusive thoughts at times. Most people,
however, pay little attention to them, so they don’t have much power. Alongside
situational factors (thoughts about my upcoming driving test are more likely to intrude
while watching a Formula 1 race), rumination (“Why am I thinking this?“), or an
entirely conscious decision to elaborate a thought (e.g., happy holiday memories), may
also maintain such thoughts. Thus, associations are partly automatic, but are also
subject to conscious intent.

c. The connection between two thoughts can differ reciprocally: In many cases
cognition A leads to cognition B as often as vice versa. A similar number of people
will come up with white when thinking of black as vice versa. Depending on learning
conditions there are important exceptions and cognitive one-way streets (thought A
leads to thought B, but not vice versa). This is often the case for superordinate terms.
While most people will immediately think of bird when they hear turkey; the word
bird will probably not trigger associations with turkey (except perhaps in the United
States at Thanksgiving). More likely they will cycle through more common bird
species (e.g., robin, eagle) before coming up with turkey—if at all. Another reason
why turkey and robin will more easily trigger bird than vice versa is that the cognition
bird is connected with a much larger number of cognitions than is the cognition
turkey. The more associations the lower the probability of activating a specific
connection when hearing, thinking, or seeing a word. The opposite pertains if the word
has only few associations.

Lopsided associations are also common in OCD. A person with an exaggerated fear of
getting cancer may associates the word cancer almost exclusively with the meaning of
illness and may not come up with other possible associations (Cancer the crab in the
zodiac). Alternative concepts/cognitions exist, but their associative strength is reduced
in the course of the illness. In patients, there is often a more powerful attraction to
compulsive cognitions than to neutral ones (e.g., the train of thought more easily leads
from the cognition Taurus to cancer than vice versa).

d. The fan effect and association splitting: The strength of the association between
thought A and thought B (i.e., associative strength) depends partly on the number of
associations thought A has. This was first demonstrated in studies by the psychologist
John R. Anderson and his colleagues in the United States, during the 1970s. A child
learning the word date will at first most likely associate this with the concept of time,
for example, clock or Tuesday (see Figure 3a). At this stage the associated binding
power between date and time is very strong. However, later on as the child learns
other meanings for date, like a type of fruit or going out with a person, this connection
becomes less dominant.

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The association energy will continue to spread from date to time, but also to new
words, such as fruits (e.g., bananas, oranges), or girls/boys, and love (see Figure 3b).
We will return to this later, because most obsessive thoughts show very pronounced
one-sided connections with few alternative associations. An efficient connection
between these obsessive thoughts and new thoughts will not entirely banish an old
association, but it may at least weaken it. In other words: new connections or the
strengthening of formerly weak associations may lead to a wider distribution of the
association energy.

calendar
clock

date time future

tuesday

Figure 3a: Learning the new word date is initially used and stored exclusively in the sense of "point in
time."

up-to-date calendar
clock

girl-/boy-
date time future
friend

prom fruit tuesday

Figure 3b: Learning further meanings (links or associations) of the word date
Note for figures 3a & b: Association splitting (for a better overview, reciprocal associations are shown
only for time - date). Figure 3a shows very strong associations between date and time because no other
associations for date are yet present. The learning of new meanings as shown in 3b leads to an
automatic decline in association spreading from date to time because the association energy now also
spreads to other concepts. This is called the fan-effect. The original association remains fairly strong,
but it is considerably weaker than in 3a. The association energy from time to date was comparably weak
from the start, since many associations already existed for time (as was the case for bird and turkey).

3. Obsessive thoughts... are normal, and yet not!

Early investigations by Josef Rachman and his colleagues in Canada, in the 1980s, showed
that the contents of most compulsions are to some extent also known to people without OCD.
We were able to confirm this assumption in a recent survey of 100 healthy participants. For
instance, 53% agreed the statement “Before leaving the house, I reassure myself several times
that I have the door key with me,“ and 67% confirmed that, “Before going on vacation, I
check several times that electric devices are unplugged.” Other examples are displayed in the
next table.
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Table 1
Percentage Statement
yes
42% To find inner peace, I perform certain rituals.
63% Sometimes, I feel strong anger toward people I love.

48% Sometimes I have bad thoughts that I do not want to think.

37% When leaving the house in a hurry, my thoughts often dwell on the question
whether I have turned off the stove or not.

In contrast to OCD patients, healthy persons can rid themselves of these thoughts fairly easily
and do not get thrown off balance because the thoughts automatically fade away (as
mentioned above, most thoughts disappear quickly if we don't try to hold onto them). They
are also better able to counter such thoughts with logical argument (e.g., “No one gets sick
from coughing once,” or “Even if the door is unlocked, nothing much will happen—after all,
this is a safe area”).

Furthermore, most healthy persons perform some kind of rituals or compulsive actions,
whistling a particular tune to prevent harm to oneself or others, following a ritual at the plate
so that the “baseball gods” will be merciful, knocking on wood for reassurance, continuously
checking pockets for the passport at the airport. None of these rise above the status of foibles.
But as in OCD, even otherwise healthy persons may experience some discomfort if these
rituals cannot be performed.

There is a dimensional transition from normal to pathological rituals (certain types of

compulsive actions may also be observed in children, and are part of normal development).
Serious obsessive thoughts and compulsive actions are stronger, more obtrusive, and may
pose a social problem for the individual. But in their original form, they do not represent a
completely separate class of thoughts.

4. Existing treatments for obsessive thoughts and compulsive actions

Before we explain our approach in greater detail, we will briefly outline other
psychotherapeutic interventions for OCD. These interventions should preferably be facilitated
by a therapist and are not intended as self-help treatments (for lack of space we will not touch
on the issue of drug treatment of OCD).

Exposure in vivo or in sensu: The patient is confronted with anxiety-provoking situations—

either mentally (i.e., in sensu) or in reality (i.e., in vivo)—in order to challenge the validity of
obsessions and expose them as absurd and unfounded. The patient is asked to do things that
normally lead to severe anxiety (e.g., leave the house after checking the door only once; wash
hands only once instead of ten times; throw things out; look into the mirror only once to
check one's hair). Omitting compulsive actions will at first lead to a strong increase in
anxiety, which will, however, automatically decrease over time. This exercise provides the
corrective experience that the expected consequences of certain fears (e.g., burglary,
infection) do not occur, and that fear continues to rise only to a certain point and then flattens.

Confrontation with obsessive thoughts: The British psychologist Paul Salkovskis proposed
that OCD patients should record their obsessive thoughts on an endless tape (e.g., recording

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the sentence, “I could kill my children.”) and listen to it. Again, the aim of this exercise is to
learn that the fear evoked by such thoughts eventually attenuates, and that these thoughts are,
after all, just thoughts.

Clarifying the exaggerative nature of obsessions: Patients are confronted with the
exaggerated, counterproductive and irrational nature of their thoughts. For example, checking
the door ten times will attract rather than scare off burglars, because the thief may conclude
that someone adopting such high security measures must have a lot worth breaking in for.
Similarly, the risk of contracting a skin condition actually increases with exaggerated hygiene,
because it harms the natural safety layer of the skin (this is why many persons with obsessive
washing require dermatological treatment). Patients are shown how unlikely, exaggerated and
in part, absurd their fears are. For example, nobody gets HIV just by shaking hands with a
person who has HIV or AIDS. Or it is almost entirely impossible for someone to run over a
pedestrian without noticing.

Distinguishing between thoughts and actions: Another approach aims at showing patients
that there is a huge difference between thinking a “bad“ thought and acting on this thought.
For example, passing thoughts of suicide are not uncommon in the normal population. About
every fifth person have such thoughts at some time in their life, but we would certainly hear
about it if 20% of the population actually went through with it! If every thought like, “I will
kill him.” or “I would like to beat him up.” were acted upon, world population would be
greatly reduced—and pretty much everyone else would be in jail. It's an interesting thought
experiment, but the fact is that our minds are a “free zone,” and thoughts about actions are
little more than musings. They can be used to test out ideas that we would never implement in
the real world because of powerful moral, social, and self-control mechanisms. Most OCD
patients who experience such worries pose absolutely no threat to other people! Patients with
OCD exhibit a so-called thought-action-fusion: Thinking certain thoughts convinces people
that they would be able to carry them out (“If I think such and such, I am also able to do it.”).
Considering our permanent exposure to violence through the media, it is inconceivable that
we would have only innocent fantasies populated by elves and little lambs. Accordingly, most
people report on questionnaires that they have sexually explicit, violent, or other thoughts of
which they are ashamed. In contrast to OCD patients, most people are not worried about these
thoughts and can easily differentiate between thoughts and actions.

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5. What amplifies obsessive thoughts?

Suppression of thoughts: As previously
explained, our associations are only partly under
our control. We cannot actively stop all of our
thoughts. The contrary is true when we actively
suppress our thoughts: Suppressed thoughts tend
to become amplified. Try yourself: Please do not
think of an elephant for the next minute...
Big 5 – Elephant by TheLizardQueen (4.2.2009)

Let’s be honest: You couldn't do it. In fact, you probably spent more time imagining an
elephant in just these few seconds than you have over the past week. This experiment can be
varied ad infinitum. And the more emotional the content the stronger the effect!

Paradoxically, the attempt to suppress a thought

strengthens it. Many patients with OCD use thought
suppression, which leads to an unwelcome increase in
obsessive thoughts! Rather, it is more helpful to monitor
such processes with a sense of detachment, that is, without
interfering. Like a visitor to a zoo, watching a predator
through bars. The thoughts eventually subside and pass by
Eye of the tiger by quinn.anya (4.2.2009) like thunderclouds.

Brooding (rumination): Deriving a model of illness from significant events in a patient's life
is an important part of psychotherapy. But it is only one part, and it needs to be developed
under the guidance of a therapist. Without such
guidance, the patient may end up in a conceptual dead-
end. There is little point in brooding about the cause of
the obsessions or why it has taken hold. In fact,
brooding often has the reverse effect, intensifying the
power of obsessive thoughts. And even if the "cause"
or trigger of OCD is "identified" (e.g., mom
compulsively enforced hand-washing because one of
your classmates died during the flu epidemic in the 3rd
grade, etc.), the compulsion will not simply disappear, I'm thinking of... by gutter (26.1.2009)
since many other factors may prop up the obsessive-compulsive chain in the present.

Avoidance and safety behavior: Avoidance behavior describes the active avoidance of, or
even flight from, subjectively dangerous situations (e.g., giving up driving out of fear of
hitting someone, not touching anything on buses out of fear of disease; removing knives from
one’s home out of fear of slashing a family member). A kind of anticipatory obedience often
develops: Situations are avoided in which there is even a remote chance that obsessions or
compulsions will occur. In extreme cases the patient may become completely homebound.

Safety behavior refers to rituals that are performed to prevent a disaster, danger, or
responsibility for harm. Examples might include wearing gloves for fear of germs, or good-
luck charms to ward off ill. This represents a hidden form of avoidance. The feared situation
is not completely avoided, but neither does one look fear in the eye (and experience it as

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unfounded or exaggerated). Although safety behavior leads to short-term relief, it intensifies

obsessions in the long run because it creates the illusion of effectively controlling fear.
Likewise, avoidance enhances anxiety and increases OC symptoms as no corrective
experiences are gathered to deal with critical situations.

6. Association splitting
Our technique, called association splitting, is based on the way in which associations and
cognitions work, as described in the preceding paragraph on associations. It makes use of two
basic mechanisms: The linking of new cognitions with existing thoughts, or the strengthening
of older associations, automatically leads to a weakening of competing associations, as we
demonstrated in the date-time example. Another important aspect of our method is the fact
that the strength of cognition A in relation to B is not necessarily as powerful as the strength
of cognition B in relation to A!

Obsessive thoughts may be viewed as firm assemblies of associations that mutually strengthen
each other, creating a vicious circle. Essentially harmless events increasingly act as triggers of
obsessive thoughts (event: touching a pedestrian on the street ➔ obsessive thought: “I just
caught AIDS.”; a clattering sound in the car ➔ obsessive thought “I hit someone.”; seeing the
letters CA ➔ obsessive thought: “I’m getting cancer.”).

Why are these thoughts so powerful? Giving in to these obsessive thoughts by performing
compulsive rituals, or by avoidance or safety behavior (see last section) may bring about
short-term relief and reduce anxiety. However, the obsessive network is strengthened. The
associations become stronger, and the subjective perception of immanent danger is cemented
(see figures 4a and 4b).

Figure 4a: Formation and perpetuation

of OCD.
Event An event triggers negative intrusive
thoughts that in turn lead to new
lead to
negative associations. In people with
Negative OCD, these foster negative emotions
Intrusive thought
associations such as anxiety and disgust.
Compulsions bring about minor but
immediate relief from these feelings.
lead to

Unfortunately, they also strengthen the

connection between obsessive thoughts
and compulsive behavior.

lead to Negative
 emotions 
Compulsions short term reduction of

(neutralizing actions)

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Figure 4b: Formation and perpetuation

Man wearing a of OCD (example)
red T-Shirt
An event (in this case, an image of a
lead to lead to man wearing a red T-shirt) activates
HIV, AIDS, certain intrusive thoughts (e.g.,
Red Blood death,illness
“blood“) that in turn trigger other
negative thoughts (“HIV, death,
illness“) and negative emotions such as

lead to
anxiety and disgust. The short-term
decrease in negative emotions
resulting from the performance of a
compulsive ritual further strengthens
the connection between the obsessive
lead to Anxiety thought and the compulsion (in this
 Disgust
 case, washing). Avoidance and safety
behavior also perpetuate vicious
Cleaning short term reduction of circles.
(neutralizing actions)

From this perspective, obsessive thought circles differ from other associative circles in the
following ways:
1. Cognitions in the obsessive network are strongly intertwined, yet the number of other
associations is reduced (e.g., cancer is only thought in the meaning of illness, while
the sign of the zodiac does not come to mind; a knife is seen exclusively as a weapon,
never as cutlery; a noise under the car is interpreted as a mortal danger, not as a stone
that got kicked up by the tire). OCD patients process ambiguous concepts, that is,
concepts originally connected with a variety of other cognitions, only in the context of
the obsession, and do not connect them to other, more neutral, cognitions.
2. At the same time, there are one-way connections between neutral and obsessive
thoughts maintaining obsessive worries.

The association chain is a one-way street:

Approaching a hospital (originally neutral) ➔ fear of contact with infected people
(anxiety) ➔ “I could get infected.“ (obsessive thought). However, in OCD patients
this process does not operate in the opposite direction (illness ➔ hospital ➔ cure!).

Thoughts start to spin in circles. And it may get even worse: Worries become more powerful
as a result of brooding (rumination), and the OCD patient may see no way to gain relief other
than by performing compulsive actions. As a result he or she increasingly becomes a slave to
obsessive thoughts and compulsive actions like washing, cleaning, checking or collecting,
which increasingly come to dominate his or her life. This vicious circle becomes increasingly
powerful over time, and longitudinal studies have shown that compulsions tend to increase
over the course of the illness if untreated, even though they are treatable with psychotherapy
and/or medication. In the end, this gives rise to new obsessions, and rituals and compulsive
actions increase to the point where no trigger is needed to set off an avalanche of repetitive
behaviors.

7. Reduction in obsessive thoughts using association splitting

Our technique follows almost seamlessly from the previous explanations. At the core of it lies
the need to expand the repertoire of the shared cognitions associated with the obsessive

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 Moritz & Jelinek: Association splitting

thought, that is, new associations have to be created and currently weak associations to neutral
or positive cognitions have to be strengthened. At the same time, everything that perpetuates
obsessive thoughts must be avoided. It is important not to initiate fruitless brooding (e.g.,
“Why does it have to be me?”), and not to suppress obsessive thoughts. The more you try to
rid yourself of them, the stronger these thoughts will become. The elephant example above is
illustrative.

The following reparative processes are set in motion when you apply this principle to
obsessive thoughts (see Figure 5): Creating and strengthening neutral and positive
associations automatically weakens, via the fan-effect, associations that trigger anxiety and
OCD behavior. If these new associations are connected to positive feelings, these interfere
with negative emotions and decrease the urge to perform compulsive acts. It is important not
to try to suppress negative feelings as this only strengthens OCD thoughts. Try to deal with
these thoughts and feelings by observing them from a distance, much as you would a tiger in
a cage (see above).

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 Moritz & Jelinek: Association splitting

Event
1 2

Positive/neutral Negative
Intrusive thought
associations associations

lead to
lead to

- 3

 emotions 
Positive Negative
 emotions  reduce

reduce Compulsions lead to

(neutralizing actions)

Event
4 1 2

Positive/neutral Negative
Intrusive thought
associations associations
lead to
lead to

+ -
5 3

Positive Negative
 emotions 
reduce
 emotions 
reduce Compulsions lead to

(neutralizing actions)

Figure 5a: Gradual change in obsessive thoughts (The next figure shows an example)

15
 Moritz & Jelinek: Association splitting

Man
Man wearing
wearing aa
red
red T-Shirt
T-Shirt
1 2

Cherry, HIV,
HIV, AIDS,
AIDS,
Red
Red Blood
Blood
roses, love death,
death, illness
illness

lead to
lead to

- 3

Positive ® Anxiety ®
 emotions
 reduce
 Disgust
Disgust

reduce Cleaning
Cleaning lead to
(neutralizing
(neutralizing actions)
actions)

Man
Man wearing
wearing aa
red T-shirt
red T-shirt
4 1 2

Cherry,
Cherry, HIV,
HIV, AIDS,
AIDS,
Red
Red Blood
Blood
roses,
roses, love
love death,
death, illness
illness
lead to
lead to

+ -
5 3

Positive
 emotions 
reduce
®

Anxiety ®

☺ Disgust
Disgust
emotions
reduce Cleaning lead to
(neutralizing actions)

Figure 5b: Gradual change in obsessive thoughts (example)

The spontaneous appearance of negative thoughts and worries is a normal experience. What distinguishes people
with OCD is how they appraise these thoughts. If, for example, they see a red T-shirt on the street, their thoughts
may automatically tend toward blood and HIV (see 1 in the figure), which is accompanied by negative
associations (HIV, illness, see 2) rather than toward direction 4 (positive thoughts: roses, love). New, more
neutral or positive associations weaken associations that trigger anxiety and OCD via the fan effect (association
splitting), and this process gradually alters the associative network. The number of associations under 4
increases. Newly created neutral and positive associations automatically decrease the impact of negative
emotions connected to negative cognitions, thereby reducing the urge to perform compulsive rituals (see 5).
Important: Do not try to suppress negative associations, since this only makes thoughts stronger and more
intrusive! The same applies to negative emotions. Try to contemplate those cognitions and feelings like an
outsider. Create a sense of inner distance that allows you to be a neutral observer.

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 Moritz & Jelinek: Association splitting

To create and strengthen neutral and positive associations please do the following:

1. Seek out a quiet place. Perform the exercises in a relaxed atmosphere and when you
are not plagued by obsessive thoughts.
2. Write down individual words or think of images that represent an important aspect of
your obsessive thoughts system, that is, cognitions that are almost always present in
the disturbing thoughts (for the examples above: blood, cancer, door, lock, burglar).
3. Select at least 2 words from this set (e.g., door, lock, burglar).
4. Write down at least 3 associations you connect with each obsessive-compulsive
cognition, but which at the same time:
➢ are neutral or positive (that is, not fear-provoking; associations that lead outside the
obsessive network), and
➢ make sense (words, say, that rhyme or connect in meaning; e.g., not: “door - hair
spray“)

Example: door-four, door-The Doors (band), door-adore, door-gold (from “d’or”)

For many OCD sufferers, the technique works better with visual material. You can either
draw associations or—much easier—find images via search engines like
http://images.google.com (see Figure 6).

AIDS cancer, libra, vigin…

CANCER

dancer
answer

AIDA = ship
novel by Henry Miller

Figure 6: Positive and neutral associations to “AIDS” and “cancer”

Note: Pictures encourage the deep formation of new associations. All of these pictures were downloaded via
Google Images (http://images.google.com.).

Associations may also be funny! Avoid any associations that run directly counter to your
obsessive thoughts (i.e., “Cancer—I’ll never get that“), because this contains no
alternative meaning and works like thought suppression thereby fueling the obsessive
cascade.
The examples listed in the table under section 8 introduce a variant in which associations
are not related to the content but to the verbal “form” of the obsessive thought (e.g., threat,
question). Yet, the principle is the same. If you are unable to think of any neutral
associations, ask other people for help.

5. Let these new associations become habitual by saying the obsessive thought (or
imagining a corresponding fear) either out loud or in your mind (for example, the
words door, lock, burglar), and then shortly thereafter say or imagine one of the
selected associated neutral words/pictures under 3. then again, connect the obsessive
component with a another neutral word or picture etc. For example, door ➔ four,
door➔ The Doors, door ➔ adore, doo r ➔ gold—then burglary ➔ basketball player
17
Larry
 Moritz & Jelinek: Association splitting

Bird (by approximate syllable reversal) or the old McDonaldland character the
Hamburglar. If you are a basketball fan, you know that Larry Bird was a great pass
stealer, and that his predecessor on the Boston Celtics, John Havlicek, famously “stole
the ball.” A whole other set of positive, or at least neutral cognitions—unless you
were rooting for the other team. In other words, the object is to combine one OCD
cognition with one neutral cognition, and then combine the same OCD cognition with
a second neutral cognition and so on. Do this exercise for a maximum of 10 minutes
per day. Please note: the procedure itself should not become a compulsion or a
mantra! The goal is to tap into the association energy which, for example, initially
went only from lock or door to burglary or catastrophe, for use in new associations
(see Figure 7). The strength and impact of the obsessive thought is decreased by this
diversion of energy, which in turn makes the obsessive thought easier to neutralize.
However, these association channels must be built up or released gradually. It is also
important to check the direction of the association: door ➔ four, door ➔ The Doors,
door ➔ adore … and not the other way around!

Please note: When obsessive thoughts occur, do not try to neutralize them by repeating
the new associations. The new associations should not become a compulsive ritual.

blood gun
blade

thriller cutlery

me
m
knife
knife
ekill
kill

children
B
A
spoon
blood gun
blade

thriller cutlery
washing - controlling
me m
knife fork
Core obsessive beliefs ekill
kill knife
Neutral (supporting) associations

New neutral associations rife

Week associations
children
Strong associations
Cognitions that promote compulsions

Figure 7 A: very simplified schematic of the obsessive-compulsive washing - controlling

thought “I might kill my children with a
knife.” The obsessive cognition is shown in red; the triggers “feeding” cognition are shown in yellow. New
(neutral or positive) associations are in green. The strength of the arrows shows the strength of the association
flow.
The figure illustrates that obsessive cognitions are strongly and mutually intertwined with each another. The
obsessive spiral is triggered by a number of essentially harmless cognitions (pictures, words, memories). These
obsessive thoughts enhance each other and develop a powerful dynamic (illustrated by the downward spiral)
18
 Moritz & Jelinek: Association splitting

from which there seems to be no escape. The OCD patient sees no way out other than avoiding certain
occurrences or objects (e.g., locking away all knifes) or performing compulsive actions (e.g., repeating a specific
sentence to “neutralize” the thoughts). Of course, there are associations that lead out of the vicious circle (e.g.,
the person obsessed by the thoughts above could also associate "knife" with "spoon"), yet these associations are
fairly weak and, as shown, may have atrophied (the arrows pointing toward the core obsessive cognition are
stronger than the other way around!).
B: By building new cognitions or strengthening associations that point in the direction of neutral cognitions and
away from the obsessive thoughts, the connection to OCD-related cognitions automatically decreases and the
obsessive spiral automatically loses part of its energy. In the diagram, this is illustrated by the equal strength of
the arrows going in both directions and the decreasing connection of the two central obsessive cognitions. Since
obsessive thoughts often comprise multiple cognitions, it is important to apply the technique to various
cognitions (in this case, for example, “knife” and “children”).

8. Examples
Be creative! Try to come up with association words or even short sentences that are as vivid
as possible! Don't argue against or suppress obsessive thoughts (this is counterproductive, as
we have shown in the elephant exercise). Rather, focus on building up alternative meanings.
Use related words or pictures that are neutral or positive, or words that rhyme. You may also
use words that make you laugh. Make up multiple pairs with the same obsessive component
but avoid verbal chains. Examples 4 and 5 show one variant of the technique, which verbally
“diverts” the obsessive thought. This technique is especially useful for obsessions that involve
questions or aggressive obsessive thoughts. In our experience, many patients have trouble
coming up with associations that are neutral or uncharged for their obsessive cognitions. If
you experience this problem, ask a friend for help.

Type of obsession Example for an Core Exercise

obsessive thought cognition
1. Checking Killing your own children Repeat aloud and imagine visually:
Compulsion children with a knife knife knife  fork
in the kitchen kitchen knife  spoon
knife  five (rhyme!)

kitchen  smell
kitchen  Hell’s Kitchen (section of New
York City)
kitchen  cooking
kitchen  tasty
kitchen  prison („Kitchen“ is a German
word für prison – not necessarily
positive/neutral but somewhat funny!)
Using the word children, you may recall
situations in which your children were
happy, etc.
2. Checking Checking the lock Lock lock  Heather Locklear (actress)
compulsion prevent burglary Burglary lock  curl
lock  Foot Locker (company)

burglary  Chris de Burgh (singer)

burglary  Larry Bird

Checking the oven/stove oven  Sunday roast/dinner

oven/stove to prevent fire oven  Roll over Beeth’oven!
the house from
burning down fire  fireplace
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 Moritz & Jelinek: Association splitting

fire  diamond (a diamond is sometimes

described as having fire)
fire  fireflies
fire  wire (rhyme)
fire  water (elements, opposing)
fire  firebird (car)
fire  Fight Fire With Fire (song by
Metallica)
3. Washing Body could be forest forest  grass
compulsion contaminated by worm forest  Forrest Gump
worms during a walk body forest  oxygen
in the forest forest  Forrest Whittaker (actor)

worm  firm, term (rhyme)

worm bookworm
worm  useful
worm  warm

body  building
body  sculpture of Michelangelo/Poster
of Pamela Anderson
body  clothes
4. Checking Self-assurance (This example When such threatening thoughts come to
compulsion compulsions, is a variant of mind, don’t counter them, but reply with
brooding, e.g., “How the obviously absurd or unanswerable
do I know this?” demonstrated questions:
“Am I really feeling technique, in
btter?“ “Am I a this case “Is the universe really infinite?”
good person?“) starting with “How many grains of sand are there?”
the form and “Who will win the next NBA
not the championship?“
content of the
obsessive thought)
5. Aggressive Obsessive thoughts (This example When such threatening thoughts come to
obsessive thoughts involving threats or is a variant of mind, don’t counter–threaten. Instead,
blackmail, “You are the technique recall other threats, but in an amusing
courting disaster if in 4) context, e.g., famous quotes from movies
you do not do xyz
“In town you’re the law, out there it’s me.
Don’t push it. Don’t push it or I’ll give you
a war you won’t believe.”
(quote from Rambo, First Blood)
“Fredo, you’re my older brother and I love
you. But don’t ever take sides with anyone
against the family again. Ever!“ (quote
from The Godfather)
6. Washing Germs are germs germs  the firm (think of cover of
compulsion transmitted by bus book by John Grisham
passenger sraps on bacteria germ  Germaine Jackson (brother of
buses Michael Jackson)
germ  jam
germs  Germany (phonological
association)
germ  Gemini (phonological association)

bus  fuss
20
 Moritz & Jelinek: Association splitting

bus  car
bus  Buster Keaton
bus  movie Ghostbusters (think of
melody)

bacteria  yogurt (these bacteria are good

for you)
bacteria  criteria
bacteria  vaccine (made from attenuated
or dead bacteria)
7. Checking Looking or thinking blue blue  true blue
compulsion about the colors blue black blue  sky
and black evokes blue  blueberry
fear of causing harm blue  blues (perhaps the song “I still got
the blues” by Gary Moore)

black  chimneysweep (symbol of luck)

black  coffee (and hold the sugar)
black  dark chocolate
black  white
black  Frank Black (comedian in movie
School of Rock)
Black  Sirius Black (Harry Potter)

9. What you should not do?

As discussed above, associations should be built up by connecting the obsessive thought
component with a neutral or positive association—and not the other way around (thus,
associate cancer ➔ libra (the scales), but not libra ➔ cancer). The associations must be
neutral or positive; a connection between asbestos and the word garbage would not be useful,
even though it is a new connection and diverges from the association asbestos ➔ suffocation!
It is important to “split” specific terms and words that are at the core of your obsessions, and
that elicit tension and fear. The technique can only be effective if you look into the “eye of
storm.”

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 Moritz & Jelinek: Association splitting

10. Appendix—further examples

GUILT
guild

Gilberto Gil (musician)

Gilt borders

Heather Locklear LOCK

Lockheed Blackbird

L.O.G.G. (Jeans brand)

Lok = German for
„locomotive“

HARM
Judge Harm (Simpsons) Harmony

ham
Harmoica

22