REGULAR ARTICLE

The Core Conflictual Relationship Theme (CCRT) Applied

to Literary Works: An Analysis of Two Novels Written
by Authors Suffering from Anorexia Nervosa
courses and developments of the
Aglaja Stirn, MD1* ABSTRACT
novels. Both the positive and negative
Objective: Two literary works of
Gerd Overbeck, MD2 authors suffering from anorexia nervosa
as well as the conscious and unconscious
Dan Pokorny, MD3 were analyzed with the method of the
relationship patterns were clearly
expressed.
core conflictual relationship theme
(CCRT) to prove that novels and/or per-
Discussion: The results indicate that
sonal accounts may reveal the same
after certain adjustments, the CCRT
maladaptive relationship patterns typi-
method may be successfully applied to
cally revealed in psychotherapy sessions
data obtained from sources other than
with this nosologic group.
psychotherapy sessions. ª 2005 by Wiley
Method: Two novels were selected Periodicals, Inc.
which promised applicability of the
CCRT method due to the completeness Keywords: core conflictual relation-
of the described relationship episodes. ship theme; anorexia nervosa; literary
works
Results: After several methodologic
adjustments, the application of the
CCRT method revealed the different (Int J Eat Disord 2005; 38:147–156)

are of high literary quality. Style and descriptions

Introduction
Written accounts about diseases are numerous.
The diseases described are diverse, as are the
ways in which they are described. Many literary
works describe the syndrome of anorexia nervosa.1
In the current research, two works were selected:
The House of the Crazy Kids by French author,
Valerie Valère (1980), and Die Suppenkasperin2 by
Swiss author, Andrea Graf (1985). These two novels
were selected for three reasons. First, they are par-
ticularly suited for the application of the core con-
flictual relationship theme (CCRT) method because
the description of relationship episodes (RE)
was exhaustive and detailed. Second, the novels
Accepted 16 August 2004
The authors thank Dr. Angelika Stirn for her patient assistance
and help.
*Correspondence to: Aglaja Stirn, MD, Department of Psychiatry
and Psychotherapy, I, J.W. Goethe University Hospital (House 93),
Heinrich-Hoffmann-Strasse 10, D-60528 Frankfurt am Main,
Germany. E-mail: stirn@em.uni-frankfurt.de
1
Department of Psychiatry and Psychotherapy, I, J.W. Goethe
University Hospital, Frankfurt, Germany
2
Department of Psychosomatic Medicine and Psychotherapy,
J.W. Goethe University Hospital, Frankfurt, Germany
3
Department of Psychosomatic Medicine and Psychotherapy,
University of Ulm, Ulm, Germany
Published online in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/eat.20156
ª 2005 Wiley Periodicals, Inc.
are nuanced and differentiated. Third, detailed
biographic data of the authors are available for
correlative analysis.
Other important motives for the selection of
these particular novels were the intentions to
obtain as pure course descriptions of psychothera-
pies as possible and to analyze therapies that have
maximally divergent outcomes. Valères’ book (she
was born in 1961) is a deeply depressing account of
her time in the isolation tract of a psychiatric hos-
pital where she was hospitalized for 4 months
because of severe anorexia nervosa at the age of
13. She wrote her book 2 years after that time.
Andrea Graf (who was born 1963) decided to write
about her struggle with anorexia nervosa when she
was 21 and had been suffering from her disease for
5 years. Her account was published in 1985 and
1
A list of works that describe experiences with eating disorders
in German language may be ordered from the first author.
2
Its untranslatable title was derived from the famous moral
story by a 19th century German author and psychiatrist, Heinrich
Hoffmann. The story describes a boy who would continuously
refuse to eat his soup and who eventually would die. The word
Suppenkasper has become an idiom in the German language for
individuals not eating well and, therefore, remaining skinny, and
most importantly, creating problems for their parents through
their food refusal. Suppenkasperin denotes the female form of the
noun. The English translation of the story in the original book is,
‘‘Augustus, who would not have any soup.’’

Int J Eat Disord 38:2 147–156 2005 147

STIRN ET AL.
deals with her experiences of psychotherapy, the
course of her disease in general, and the people
involved (especially her parents). The accounts differ
drastically with respect to the authors’ evaluation of
their therapeutic processes. Valère judges her stay in
the hospital as devastatingly negative, whereas Graf
takes a positive, idealizing stance in her account.
Data
This study is part of a multimethodologic research
project on anorexia nervosa at the Department of
Psychosomatic Medicine and Psychotherapy at
J.W. Goethe University, Frankfurt, Germany. Next
to case studies and meta-analyses of scientific
reports, literary works written by people suffering
from anorexia nervosa were analyzed in an attempt
to understand the psychodynamic processes
involved in this disease. It was hypothesized that
the relationship patterns and CCRTs expressed by
the authors would reveal similarities with patterns
emerging in research with patients at Frankfurt
University. The latter data were already validated
by the literature on eating disorders. Thus, the
goals of the study were to obtain additional proof
for the validity and reliability of the CCRT method,
and to find out more about the psychodynamics
involved in anorexia nervosa.
Valerie Valère: The House of the Crazy Kids
The Valère book consists of 168 pages divided
into 9 chapters and an epilogue (which was
excluded from analysis). Valère describes her
mother as being full of hate, as an egoistic person
who has sexual relations with others besides her
father, and as a mother who wants to dominate
her. The father is frequently absent and has lovers,
too. The brother is presumably homosexual. Valerie
experiences the stay at the isolation tract at first as
so horrifying that her sole behavior is total opposi-
tion against any contact with food, hospital staff, or
fellow patients. She experiences everybody as hos-
tile. However, this isolation is partly due to the
hospital policy to allow contact with fellow patients
or other people only after an increase in weight is
achieved. Books and writing utensils are removed
when weight is lost. Thus, Valerie’s contact is nar-
rowed to the nurses who lock her away in her room
and only bring her food rations or try to coax her
into eating—at times even with physical force. The
patient clientele at the isolation ward consists of
severe psychiatric cases. Finally, Valerie realizes
that her only way out of this nightmare is to gain
148
the amount of weight desired by the hospital staff.
She eventually succeeds—yet her hatred remains,
and 2 years later (when she is 15) turns to the
writing of her account.
Andrea Graf: Die Suppenkasperin
The Graf book consists of 104 pages divided into
6 chapters plus and an epilogue by Andrea’s thera-
pist (which was excluded from analysis). The book
was written ‘‘while the disease still persists’’ (as
stated in the flap text and explained in the epilogue
of the therapist) and has been ongoing for 5 years.
The book also contains excerpts of Andrea’s perso-
nal diary. The author describes her father and
mother as being exempt of any peculiarities and
her youth as normal. At the age of 16, she feels
the desire to lose weight. At first, she finds appre-
ciation among her peers but then the vicious circle
of pathologically gaining and losing weight begins,
leading to physical failure after extreme diets.
Again, she finds joy in eating, but then she hungers
anew, going through depressive states and dreams,
followed by alternations between bulimic stuffing
and vomiting and extensive use of laxatives. She
receives years of psychotherapy. With a few excep-
tions, her peer group including her parents is com-
pletely incomprehensive. Yet, Andrea shows no
signs of aggression or rejection. Finally, she passes
her high school degree and attends university to
study psychology. The book is an attempt to inte-
grate the two persons Andrea describes as consti-
tuting her personality into one and to finally find a
meaningful role in life.
Method and Methodologic
Adjustments
The CCRT method is one of several methods used to
describe central relationship patterns in psychothera-
peutic sessions (Luborsky, 1990). This method is espe-
cially qualified to identify intrapsychic and interpersonal
functional and dysfunctional relationship patterns
(Kächele, Dengert, Eckert, & Schneckenburg, 1990; Stirn,
1996; Strauss et al., 1995). The CCRT method is widely
established and validated (refer to Deserno et al., 1998;
Firneburg & Klein, 1993; Grabhorn & Stirn, 1997; Luborsky
& Crits-Christoph, 1990). The concrete procedure has
been described repeatedly (Albani, Pokorny, Dahlbender,
& Kächele, 1994; Kächele et al., 1990; Luborsky & Kächele,
1988; Luborsky & Crits-Christoph, 1990, 1998).
The method is based on the idea that a description of
experiences of relationships contains subject-object-rela-
tionship patterns, which are prototypical and characteristic
Int J Eat Disord 38:2 147–156 2005

for the patient. In the narrative episodes, they seem to be
contained like ‘‘engraved clichés’’ (Kächele et al., 1990). Initi-
ally, the method was developed to describe interpersonal
relationship patterns in transference (Luborsky, 1988). Nor-
mally, for an analysis of narratives, so-called REs are identi-
fied from verbatim transcripts of the patient reports made
during the therapeutic session. REs describe a relatively and
clearly demarcated narrative episode about relationships
with one’s self or others. Although an entire session may
have the characteristics of a narration only, explicit expres-
sions about relationships are used. According to Luborsky
(1991) the quantitative identification leads to the CCRTs. He
estimates that the CCRT components occurring most fre-
quently in the text also represent the central and important
parts of the patient’s relationship experiences. Therefore,
quantities may be transferred into qualities.
The CCRT method consists of three independent, sin-
gular components in the sense of an imagined interac-
tion scheme between narrating subject and object, that
is, (a) the main wish of the subject (W) as a desire,
intention, and ‘‘derivative of drives’’ in the psychoanaly-
tic sense; (b) the main responses from others (RO); and
(c) the main response of the self (RS). These variables are
understood as controlling and executive devices of the
two instances in the psychoanalytic construct of the
‘‘apparatus of the soul.’’ They are divided into positive
and negative reactions. Negative defines a reaction that is
restrictive to the patient’s fulfillment of a wish, and posi-
tive means that a patient’s wishes have been fulfilled. To
achieve comparable statements, the use of standardized
categories was introduced. For our study, we referred to
the German translation of the list of standardized cate-
gories No. 2. This list contains 34 wishes, 30 reactions of
the objects, and 30 reactions of the subject. These were
furthermore divided into eight clusters per component
(for details, refer to Luborsky, 1991).
In the course of its development, the CCRT method
has been proven to be useful both in cross-sectional and
single-case studies. A single case study with narrative
material collected from several sessions allows the search
for relationship patterns specific for individual objects,
life or therapy phases, and session settings. Verbatim
session protocols serve as a text base in the studies. The
goal of the current study is to examine whether an artistic
literary report written by the patient can sensitively
reflect the disease and therapy process.
Our reason for using the CCRT method for the analysis
of literary works is that this method, although concep-
tually derived from psychoanalysis, promises to be a
reliable tool and could furnish valid data from a text.
Also, it is conceivable that data received from such a
method come close to a ‘‘subliminal’’ investigation of
the manifest textual content, because the psychological
concept was—with all likelihood—neither consciously
intended by the authors when writing their texts nor
Int J Eat Disord 38:2 147–156 2005
CCRT APPLIED TO LITERARY WORKS
could it have been controlled by them. This contrasts
with narrative therapy protocols in which the controlling
effects of the therapist’s personality and his/her interven-
tions in regard to the therapeutic goal of the conversation
may not be underestimated in their impact on the ses-
sion and, therefore, on the text. Thus, from an investiga-
tion of literary texts, one can expect insights into original
changes of self and object-relationship patterns, as they
may also be found in therapy protocols of positive and
negative courses of therapies, respectively.
The CCRT method has also been used successfully in
the analysis of video recordings as well as interviews with
healthy individuals, which shows the variety of the pos-
sible applications of the method, and, thus, justifies the
rationale to apply it to literary works. In addition, both
novels show similarities to narratives typically tran-
scribed from psychotherapy sessions: They deal with
personal accounts about interactions with others or
with one’s self and the feelings derived from these inter-
actions; the background for these interactions in both
novels is the same psychosomatic disease—anorexia ner-
vosa; and the persons who are dealt with in these inter-
actions are the same persons normally found in the
verbal accounts of patients in psychotherapy, that is,
therapists, hospital staff, mother, father, and friends.
However, an application of the method to literary works
requires certain methodologic adjustments. First, diffi-
culties arise with respect to the segmentation of the
novels that is indispensable to obtain data on the possi-
ble course of development. In the analysis of short-term
therapies, the courses are subdivided into thirds (i.e.,
initial phase, phase of involvement, phase of detach-
ment), although other ways of subdividing a therapy are
also possible (Stitz & Walter, 1998). We retained the divi-
sions made by the authors to express their preference
regarding the course of their account. The developments
and changes of the courses are revealed to us in the
chapters—as in a therapy session, without the bound-
aries of the time division into 50 min or half-hours.
The usual approach of the CCRT method is to find the
most frequent standard categories (or category clusters)
for W, positive and negative RO, and positive and nega-
tive RS. These most frequent categories constitute the
core conflict. However, our approach to the search for
the central theme was slightly more differentiated. We
were interested in the hierarchy of the most frequent
categories. Luborsky’s search for the most frequent wish
cluster is based on the implicit assumption that the fre-
quencies of occurrence of the eight wish clusters are not
equal. Hence, as zero hypothesis, we postulated that all
clusters have the same theoretic frequency of occurrence
of 1/8 ¼ .125. Then, we tested which clusters occur sig-
nificantly more frequently than 1/8 and present them
sorted according to the frequency of occurrence. The
first, the most important cluster, is possibly followed by
149
STIRN ET AL.

other important clusters. The statistical test used was the Objects of Concern in all Chapters. This list of objects
one-sided exact binomial test with parameter 1/8. For (Tables 1 and 2) shows that Valerie is most con-
the sake of statistical safety, we applied the Bonferroni cerned with the mother, followed by the ward and
procedure of simultaneous inference, applying the cor- the nurses. In comparison, the number of REs with
rected level alpha ¼ .05/8 ¼ .00625, rather than the sim- herself is also stated. Andrea is most concerned
ple significance level alpha ¼ .05. with her self, followed by the classmates and the
After locating the general central relationship patterns, therapist.
we paid attention to patterns specific for the book chap-
ters (process) or for the different relationship objects
(transference). The standard CCRT approach consists of Central Patterns
the presentation of core patterns found for chapters (or The CCRT components (Tables 3 and 4), which
objects) investigated in isolation. In practice, however, are shown as clusters to facilitate comparison
this approach is not very useful because, as a rule, it between the two novels, reveal that Valerie’s domi-
leads to nearly the same patterns for all objects. There- nant wish is ‘‘to be distant,’’ followed by ‘‘to oppose
fore, we adopted a comparative technique. We searched others.’’ Both are explainable from the traumatic
for categories occurring significantly more frequently experiences at the isolation ward. In comparison,
within a given chapter than in the rest of the book Andrea’s book shows other dominant wishes—‘‘to
(respectively, for the given relationship object occurring assert self and be independent’’ and ‘‘to be loved
significantly more frequently than other objects). and understood’’—wishes that clearly show a con-
The statistical test used was the one-sided Fisher’s exact cern for others, that tell of a desire for relationships
test for 2
2 tables. Again, we applied the Bonferroni with others. By far, the most dominant RO felt by
correction. Valerie is ‘‘others are rejecting and opposing.’’
Andrea’s dominant RO consists of two clusters:
‘‘others are rejecting and opposing,’’ as in Valerie’s
Research Questions
book, but also of the rather positive reaction,
We were interested in the following questions: (a) Are ‘‘others are understanding.’’ Three significant
the two different developments/courses of the novels
reflected in the CCRT results? (b) Is it possible to mean-
ingfully differentiate among the various persons for TABLE 1. Valerie’s objects of concern in all of the
chapters
whom REs are described? The concluding question was:
(c) Is it possible to see these differences by analyzing the Self 54
Mother 21
texts with a method that extracts features that certainly Ward 14
have not been included consciously in the writing pro- Nurse 9
cess? In other words, are unconscious relationship pat- New nurse 7
Physician 6
terns revealed by the CCRT method? Fellow patients 6
Father 5
Night nurse 4
Dominique 4
Assistant director 3
Other physicians 3
Psychiatrist 3
Results Psychoanalysis 3
Narrative Material
In her book, The House of the Crazy Kids, Valère TABLE 2. Andrea’s objects of concern in all the
describes 54 REs with her self and 88 REs with chapters
others (objects – lower column parts). There are Self 69
142 REs in 9 chapters and 165.5 pages of text. The Classmates 9
overall density of REs is 0.85 per page and does not Therapist 9
New class 7
vary significantly among the 9 chapters (0.73–1.19 Physician 6
episodes per page, one-sample chi-square test, not Phychiatrist 4
significant [NS]). Friends 4
Hospital 4
Graf’s book contains 133 REs (69 self REs and Gym teacher 3
64 object REs) in 6 chapters and 98 text pages. German teacher 3
Religion teacher 3
The overall density is 1.36 episodes per page School Physician 3
and remains stable within and across chapters Parents 3
(1.16–1.67 episodes per page, one-sample chi- Pharmacist 3
Friend 3
square test, NS).

150 Int J Eat Disord 38:2 147–156 2005

 CCRT APPLIED TO LITERARY WORKS

TABLE 3. Valerie’s CCRT components: wishes, RO, RS

Valerie Absolute Relative p*

W n ¼ 172
W4—I wish to be distant 73 30.2 .0000
W2—I wish to oppose others 51 21.0 .0010
RO—responses of others n ¼ 225
RO5—The others are rejecting and opposing 136 60.4 .0000
PRO—Total number of positive responses of others 22 9.8
RS—responses of self n ¼ 264
RS6—I am helpless 79 29.9 .0000
RS7—I am disappointed and depressed 67 25.4 .0000
RS4—I oppose the others 47 17.8 .0640
PRS—total number of positive responses of self 12 4.5

Note: CCRT ¼ core conflictual relationship theme.

*One-sided binomial test that relative frequency is >1/8, Bonferroni correction for 8 clusters.

TABLE 4. Andrea’s CCRT components: wishes, RO, RS

Andrea Abs. Rel. p*

W n ¼ 305
W1—I wish to assert self and be independent 73 24.0 .0000
W6—I wish to be loved and understood 71 23.3 .0010
RO n ¼ 139
RO5—The others are rejecting and opposing 51 36.7 .0000
RO8—The others are understanding 49 35.2 .0000
PRO—Total number of positive responses of others 82 59.0
RS n ¼ 367
RS7—I am disappointed and depressed 92 25.1 .0000
RS6—I am helpless 82 22.3 .0000
PRS—Total number of positive responses of self 91 24.8

Note: CCRT ¼ core conflictual relationship themes.

*One-sided binomial test that relative frequency is >1/8, Bonferroni correction for 8 clusters.

main clusters of RS emerge in Valerie’s book: ‘‘I am
helpless,’’ ‘‘I am disappointed and depressed,’’ and
‘‘I oppose others.’’ Andrea’s book is similar to
Valerie’s book in two dominant RS: I am disap-
pointed and depressed and I am helpless. However,
in her book, Cluster 4 (i.e., I oppose and hurt
others) is least pronounced.
Examination of the object patterns (Table 5)
reveals that Valerie is clearly negative regarding
mother, physician, and nurses. However, she
desires to be close to fellow patients and friends
and experiences them as understanding. Yet, she
shows negative RS such as ‘‘being unreceptive,’’
‘‘helpless,’’ and ‘‘anxious.’’ Conversely, Andrea
(Table 6) shows negative patterns regarding ward
and parents, but wants to be close to the therapist
and her friends and feels liked by them. However,
she is also unreceptive regarding her therapist and
shows a positive RS towards her girlfriend.
Course of Development
Valerie. Valerie’s book starts with the wish to
oppose others (Table 7). However, already in the
second chapter, this wish changes to the following:
to be loved and understood and to oppose others.
After approximately one half of the stay in the
hospital has elapsed, the wishes change. She
wants to be distant, wants to assert herself and be
independent, and again wants to be distant.
Towards the end of the stay, Valerie wants to be

TABLE 5. Valerie’s object patterns (CCRT)

Objects W RO RS

Mother To be distant* Is bad*** Disappointed**

Physicians To be distant** Rejecting, opposing** Oppose, hurt others**
Nurses To oppose** Control* Helpless*
Fellow patients To be close Like me* Anxious*
Ward To be close** Like me* Helpless**
Friends To achieve, help others Understanding* Unreceptive

Note: W ¼ wishes; RO ¼ responses from others; RS ¼ responses from the self; CCRT ¼ core conflictual relationship theme.
*p < .05. ** p < .01. *** p < .001.

Int J Eat Disord 38:2 147–156 2005 151

STIRN ET AL.

TABLE 6. Andrea’s object patterns (CCRT)

Objects W RO RS

Classmates To be loved, understood* Rejecting, opposing Disappointed**

German teacher To be loved, understood* Helpful Respected, accepted
Girlfriend To be close* Like me Helpful
Therapist To feel good* Like me* Unreceptive*
Parents To be distant, avoid conflicts* Rejecting, opposing* Oppose, hurt others
Hospital To assert self, be independent Controlling* Oppose, hurt others

Note: W ¼ wishes; RO ¼ responses from others; RS ¼ responses from the self; CCRT ¼ core conflictual relationship theme.
*p < .05. **p < .01. *** p < .001.

TABLE 7. Course of development in Valerie’s book as mirrored by the CCRT

Chapter Chapter Content CCRT Pattern Specific of the Chapter

1 Hospitalization in the psychiatric hospital. Locked single cell. Negative experiences W: To oppose
with nurses, fellow patients, and the visiting physician. RO: Rejecting, opposing
RS: Oppose others
2 Retrospection of the time that led to the hospitalization: parents separated and W: To be understood
distant; Valerie stops eating and moves to the grandparents in Paris; consultations RO: Rejecting, opposing
with many psychiatrists; and hospitalization due to weakness under deceptive RS: Oppose others
circumstances.
3 Description of the hospitalization and the first days in the hospital. Experiences with W: To oppose
the nurses, the psychoanalyst, and fellow patients. Feelings of horror and disgust. RO: Rejecting, opposing
RS: Oppose others
4 Deals with the parents and grand parents and Valerie’s disgust with them, especially W: To be distant
their sexuality and hypocrisy. In between narratives about nurses and food. RO: Rejecting, opposing
RS: Am helpless
5 Three weeks after hospitalization. Permission to use the bath for the first time. W: To be distant
First use of library and playroom. Hateful fellow patients that frighten her. 31 kg. RO: Rejecting, opposing
Psychoanalyst threatening her. Math teacher makes her feel accepted. Nurse RS: Am helpless
returning from vacation explaining to her that eating will be the only way out.
Thus, first few bites. Mother visits. Again refusal of food.
6 Psychiatrist and director of hospital threaten her. V. develops a fantasy of the outside world W: To be independent
from where she would take revenge and thus starts eating. Meets another anorectic RO: Rejecting, opposing
patient who is as rejecting as she was. Weight increases to 34 kg. Mother visits again. RS: Am helpless
Is allowed to paint and to walk outside her room. Takes interest in other patients.
Weight decreases to 33 kg and all privileges are again taken from her. One male
nurse encourages her. A third anorectic patient is hospitalized and the 3 girls
try to help each other.
7 Nurses and the fellow patients. Weight increases to 35 kg and thus, mother visits. W: To be distant
Valerie hates her and her hypocrisy. Session with the psychiatrist—total opposition. RO: Rejecting, opposing
Valerie’s birthday. Mother visits—Valerie experiences her as sadistic and RS: Am disappointed
as taking advantage of her. Three days later her father visits and brags about the bad
relationship with her mother. Andrea experiences the father as totally
misunderstanding and lacking any interest.
8 Fellow patient is tranquillized. Valerie writes a story of a village where all inhabitants are W: To be distant
members of the hospital in disguise. Descriptions of the parents, especially the RO: Rejecting, opposing
mother. Imaginations of family therapy sessions where hypocrisy of the mother RS: Am disappointed
becomes evident. 3 months of hospitalization. Valerie’s interest in the fellow
patients increases (a 4th anorectic and a 2nd suicidal patient have been hospitalized).
Mother visits again, memories of porn videos and group sex activities of the
parents arise. Father visits too—experience is as bad. 15-year-old brother
visits and throws the father out.
9 Description of the last 3 days in the hospital. Recapitulation of the 4 months and W: To oppose
entirely disconsolate outlook. Back at home with the mother, where nothing has RO: Rejecting, opposing
changed—hypocrisy, lies, threat, sex partners. Valerie admits that it is impossible RS: Am disappointed
for her to build a relationship with anyone.

Note: CCRT ¼ core conflictual relationship theme; W ¼ wishes; RO ¼ responses of others; RS ¼ responses of self.

distant and to oppose others. The main wish is to
be distant. Throughout the entire book, the ROs
remain the same: Others are rejecting and oppos-
ing. It is very interesting to note the initial oppo-
sition in Valerie’s RSs that changes towards
helplessness in the middle of the book and ends
with the main feeling of disappointment (as if her
opposition was broken and she was left without a
possibility of a constructive RS). In Valerie’s book,
the positive RS and positive ROs are almost nonexis-
tent. However, in chapter 6, they increase minimally
and remain at a higher level for the rest of the book.

152 Int J Eat Disord 38:2 147–156 2005

 CCRT APPLIED TO LITERARY WORKS

TABLE 8. Course of development in Andrea’s book as mirrored by the CCRT

Chapter Chapter Content CCRT Pattern Specific of the Chapter

1 Description of events leading to anorexia: summer holidays with the mother, diet W: To be independent
leading to loss of 7 kg. Others admire her, only the gymnastics teacher warns her RO: Understanding
of beginning anorexia. Loss of weight increases. Fall holidays in Paris, loss of RS: Am accepted, am respected
strength becomes evident. At home more and more people stare at her and she feels
more and more isolated. During counseling days, teachers warn the
parents, but they don’t take any action (Andrea weighs 30 kg) and becomes
more and more depressed and weak. She starts eating again on the 1st Advent, feels
relieved. However, depressions set in again and loss of weight starts anew.
2 Andrea’s state of health becomes worse. The mother calls the family physician who W: To be understood
sends her to a psychiatrist. He can establish a contact to Andrea and asks her to RO: Understanding
write to him, since at first Andrea rejects psychotherapy. After 9 months, psychotherapy RS: Disappointed
with Mr. Hagen commences. After a physical examination Andrea’s opposition sets in and
she loses weight until 30 kg. After threatening her with a stay in a psychiatric ward, Andrea
turns to the opposite: 1 day of stuffing, next day fasting. Feelings of
hatred become stronger. Repeats the semester in a difficult class. Finds a
girlfriend and gets good marks in school.
3 One year after the beginning of the disease: Has long and intense periods of food W: To be understood
stuffing, spends all her money on food, even steals. People around her do not RO: Understanding
grasp the persisting severity of her illness due to the increase of weight. In RS: Disappointed
depression she thinks about suicide, writes to her first psychiatrist and an old Jewish
lady in the United States who both give her hope and new strength. Becomes active in a
political students’ club. However, depression and suicidal tendencies persist.
A second letter to the Jewish lady leads to a long reply in which she calls
Andrea cowardly and irresponsible.
4 Autumn: Andrea thinks intensely about suicide. None in her surrounding seems to notice W: To be understood
it. On a class trip a theater play is conceived, but Andrea feels left out and RO: Understanding
becomes jealous of her girlfriend which is relieved after a talk, so that Andrea is full of RS: Respected, accepted
self-reproaches. She starts to take laxatives (up to 70). Two collapses but she
gives alibis at the ambulance. Spring 1982 (3 years since the start of the disease) she
again falls into a depression with suicidal tendencies. Description of a session with
Mr. Hagen, who seems to be very inactive. First mention of the father with hateful
words.
5 Students in school more and more respect her and like her. Teaches a girl and W: To be distant
becomes aware of her conflicting position as a teacher/parent/therapist during the day RO: Rejecting, opposing
and being a baby (in the therapy sessions) in the evening. The date for the school trip RS: Helpless
to Rome approaches and she sees no possibility of handling her alternate
stuffing and purging. So she attempts to commit suicide. Only one fellow student
tries to find out about her situation. November till January, Andrea’s emotions
revolve around depression and activities. The final school year Andrea lives between
suicidal fantasies and depression, her nightmares become more and more
frightening.
6 Andrea turns 20. Discusses her fear of the school exams with Mr. Hagen, the W: To be independent
therapist, who doesn’t seem to understand but takes her to the physician to prescribe a RO: Rejecting, opposing
tranquilizer. She writes about two personalities living in her—the baby who RS: Self-confident
wants to remain small and the therapist who wants to help the baby become an
adult. Andrea passes her exams and starts studying psychology. On the eve of the
presentation of a paper of hers she has again stuffed herself and cannot vomit.
Thus, she takes all available medicines plus chinin, caffeine and codeine and
collapses. She is hospitalized and undergoes a controlled diet to reach
a bearable weight. However, after dismissal the disease persists and
starts anew.

Note: CCRT ¼ core conflictual relationship theme; W ¼ wishes; RO ¼ response of others; RS ¼ response of self.

Andrea. Even if the CCRT is negative in Andrea’s
book (Table 8)—to be independent being the
main wish and to be disappointed being the main
RS—the course of the book shows a certain differ-
entiation. For example, over a longer period,
Andrea wants to be understood. In the main part
of the book, she experiences the others as under-
standing her, and in three late chapters, she clearly
shows positive RS, in the sense of feeling respected,
accepted, and self-confident. In Andrea’s book, in
contrast to Valerie’s book, the levels of both PRS
and PROs are much higher. In chapter 5, there is a
peak in the PRS, but the book ends with a decrease
in both PROs and PRS.
Discussion
Our data suggest that the CCRT method is capable
of revealing the different courses and developments
of the novels. Comparing these statistical results
with the actual texts and the biographic data of the
authors, the positive and negative relationship

Int J Eat Disord 38:2 147–156 2005 153

STIRN ET AL.
patterns as well as the conscious and unconscious
relationship patterns were clearly reflected.
Valerie Valère continuously remained negative in
her feelings and experiences. Andrea Graf, whose
perceptions in general were also negative, showed
a certain variation of feelings with positive self-
relationship and object-relationship patterns devel-
oping to a certain degree.
Do these results suggest that literary works can be
as revealing as narratives of psychotherapies? Cer-
tainly, literary works about personal experiences
with a disease differ from psychotherapy protocols in
many ways. One is the missing immediateness, that is,
the missing spontaneity of a book in comparison to a
therapy session. Valère’s book was written 2 years
after her stay in the hospital, and Graf’s account was
written even later. It is certain that a written account,
and even more a published book, has undergone revi-
sions, stylistic reconsiderations, and editorial changes.
Yet, a serious autobiographic writing is always a reflec-
tive narrative process. Just as a patient does in
psychotherapy, an author uses regression and self-
reflections to remember and record past experiences.
The author starts an inner dialogue with a fictitious
reader, a process similar to that of the relationship
between patient and therapist. It is known from the
analysis of literary works, for example, books by
Holocaust survivors, that the authors relive their trau-
matic experiences during the writing process even
after 40–50 years after the dramatic events occurred
(Stirn, 2000). Their language changes, as they experi-
ence severe flashbacks of a far-away past. Yet, their
testimonies are authentic. The same is true for
accounts written about other traumatic experiences,
such as is the case with Valerie Valère and Andrea Graf.
Both authors have become serious, professional
writers, who may not simply be identified with
their works, respectively, the narrative voices of
their novels. Their work has to be credited with the
literary freedom of proceeding according to the rules
of literary depiction in terms of form and content.
However, even if the explicit authors may not be
mistaken as identical with the implicit ones created
in and by the works, the question remains: Can
authors formerly or presently affected by a disease
a posteriori write about their experiences, especially
when their literary works deal with their experiences
with psychotherapy? This question is particulary cri-
tical for research on psychotherapeutic processes,
3
In a randomized trial comprising 112 patients, Smyth et al.
(1999) discovered that asthma patients who wrote about their
disease showed improvements in lung function, and that
rheumatoid arthritis patients showed improvements in overall
disease activity.
154
because it concerns the essence of psychotherapeu-
tic efforts, that is, the change of relationship patterns.
Although, of course, hardly comparable to the
analysis of therapy protocols, the analysis of the
REs extracted from the literary works showed that,
surprisingly, these were almost entirely complete—
not as in psychotherapy protocols where the inter-
vention of the therapist may lead to a change of
subject, or the patient himself skips between sub-
jects and leaves the rater with incomplete REs. The
occupation with a certain subject in writing appar-
ently led to the completeness and subtlety that
CCRT raters always ask for to reach satisfactory
analysis results. This is probably due to the fact
that writing a literary text activates and reactivates
memories. There are no interruptions. In contrast to
therapy sessions, the time for symbolization has no
limits. Thus, writing may become a helpful process,
quite like a therapy, even more so if the subjects of
the text are traumatic experiences—which both
authors explain as the motivation to write their
accounts. For them, it was an attempt to cope with
their traumatic experiences. As empirical research
has shown, writing may have a structuring, ordering,
clearing, relieving, conquering, and curative effect
(Smyth, Stone, Hurewitz, & Kaell, 1999).3
The results of the CCRT analysis of the two novels
support this thesis. They suggest that under certain
circumstances and for certain individuals, writing
about problems, diseases, and other personal experi-
ences shows similarities with psychotherapy. For
example, the developments in the novels revealed
by the CCRT method, at least in the case of Andrea
Graf’s book, clearly indicate a change in the self and
object patterns. Whether Valerie’s remaining nega-
tivity indicates that a therapeutic effect has failed in
her case is unclear. Because Valerie also became a
professional writer, writing certainly had a meaning
to her on its own. However, if we consider the bio-
graphic data of Valerie Valère, the astounding paral-
lel between the negative outcome of the book and
the depressive course of her life became evident. She
studied at the Sorbonnne in Paris and published
another novel entitled, Mallika, which describes a
dream of a perfect yet incestuous love between sib-
lings who both commit suicide. At the age of 20,
Valerie published her third book, The White Delu-
sion, the portrait of a best-selling author desperately
struggling for ideas for a new book. After many trou-
bles, she finally succeeds to write it. However, while
attempting to hand over the manuscript to the pub-
lisher, the author dies in a car accident.
Valerie herself died at the age of 21 due to an
overdose of drugs and barbiturates. It seems that
Valerie was not able to express something
Int J Eat Disord 38:2 147–156 2005

quasisymbolical, that is, the symbolization of the
trauma and the relief connected with it did not take
place. This is true also for therapies with trauma-
tized patients, who decompensate right at the point
when they stop denying their trauma but start
recounting and symbolizing it. Thus, Swiss author,
Adolf Muschg (1981), estimates that in certain
cases writing about traumatic experiences even
intensifies or amplifies the trauma when he states:
‘‘Writing has not relieved my life. It only has made the
rip obvious that goes through my history’’ (p. 104).
The reason for that may be that during the writing
process, authors remain within themselves. There is
no intervening or correcting therapist. In writing,
authors spend a lot of time by themselves and with
the symbolized object-relationships (the implied
reader) as well as with the mute objects of the text.
Interestingly enough, Andrea Graf wrote her
account while still undergoing psychotherapy. It
remains unknown whether this was a necessary
addition to psychotherapy because of the activa-
tion that took place through the therapeutic regres-
sion or whether psychotherapy was not successful
or not sufficient.
In conclusion, we were able to document with
the semiquantitative CCRT method that the eating
disorders of both author-patients were reflected by
their texts. Also, both the negative and the more
positive courses of their respective developments
that were apparent in the biographic, exopoetic
data of the patients, were clearly expressed in
their writing.
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