Charles Dickens was dead, to begin with. There is no doubt whatever about that. Dickens was gone and buried in Westminster Abbey long before Sigmund Freud emerged as the Father of Psychoanalysis.
This must be distinctly understood, or nothing wonderful could come of the theory being advanced by Baltimore psychiatrist Stephen E. Warres, much to the interest and amusement of his colleagues at Sheppard Pratt. Dickens was dead as a doornail by the turn of the century when Freud conducted his early expeditions into childhood experience and talk therapy.
Nonetheless, Warres argues, Dickens anticipated this therapeutic revolution by more than a half-century when he wrote A Christmas Carol.
It's unlikely Ebenezer Scrooge would have coughed up the shillings for a co-pay, much less the full price of psychotherapy, so it hardly mattered to him that in his day there were no such practitioners. It happens that Scrooge didn't need them, not with all those ghosts. It was just a matter of when the miserable old tightwad would want to change.
"He's having an assisted introspection and review of his life," says Warres, who works at the Forbush School of the Sheppard Pratt Health System. "That's what psychotherapy is."
Imagine the surprise of more than 100 psychiatrists and social workers when they took their seats in the conference center at Sheppard Pratt recently for the twice-monthly lecture called "Grand Rounds." In keeping with the customary presentations on a patient or treatment regimen, the schedule announced "The Case of Ebenezer S." With Powerpoint illustrations, no less.
"I found the argument was compelling," says Scott Aaronson, a psychiatrist and the director of clinical research programs. It shed light on some fundamental questions: "By what means do people change? What will lead people in the direction of change?"
Warres, whose specialty is child and adolescent psychiatry, went the full 90 minutes. He held that A Christmas Carol is "nothing less than a primer of psychotherapy, so far ahead of its time that it could not be recognized as such, even by its author, until the world had caught up with its ideas."
Journey to self-awareness
A great popular success when published in 1843 and thereafter, the book is usually dismissed by scholars as a trifle in a grand literary career. Warres doesn't argue that it's a great book; rather he applauds its psychological insights and the way Dickens makes Scrooge's transformation believable by showing a process that serves as a "model of psychotherapy."
The ghosts of Christmas Past, Present and Future act as psychotherapists, says Warres, conducting Scrooge on a journey toward self-awareness and a more full and happy life.
That would seem to make the ghost of Scrooge's partner, Jacob Marley, the primary care physician, as he effectively "refers" the aging skinflint to the treatment offered by not one, but three specialists.
No wonder Scrooge at first seems exhausted by the prospect.
"Couldn't I take 'em all at once, and have it over, Jacob?" Scrooge asks.
Scrooge, Warres told his audience, "has fallen under a kind of outpatient commitment," his resistance to the treatment program crumbling as the story unfolds.
There is first the matter of belief. Scrooge protests that he doesn't believe Marley's Ghost is a ghost at all. Something he ate, perhaps, playing havoc with his senses. A bit of Marley wailing and chain-rattling settles the matter, however, as a terrified Scrooge falls to his knees and acknowledges that he believes.
A good thing. As Warres told his audience: without belief in the therapist, the likelihood of progress is severely diminished, if not precluded. Jerome Frank -- Johns Hopkins psychiatrist and psychotherapy pioneer -- wrote about this in Persuasion and Healing, but not before Dickens wrote about it in A Christmas Carol.
The book anticipated a legion of theorists, Frank and Freud among others, says Warres.
If Clarence Schultz in the University of Maryland's Primer of Psychotherapy argues that qualities associated with women, such as patience, caring and receptivity, are essential to the effective therapist, Dickens knew that, too. The grasp of the Ghost of Christmas Past, "though gentle as a woman's hand, was not to be resisted."
As psychiatrist and therapeutic hypnotist, Milton H. Erickson would guide patients back to their pasts, often with stops at significant occasions such as birthdays or holidays. Dickens also understood the power of this strategy. By seeing scenes of himself as a schoolboy abandoned by his father and other boys, by seeing how he spurned a young love to pursue his career, Scrooge reacquaints himself with his wounded self.
As Sheppard Pratt psychiatrist Harry Stack Sullivan understood mental health as the ability to see yourself as others do, so did Dickens. In the course of the story, Scrooge glimpses himself through the eyes of family and business associates courtesy of the spirits of Christmas Present and Future.
What a motley crew these ghosts make. The first is a kind of hermaphrodite of uncertain age and unstable form; the second a jovial giant, the third a hooded specter pointing a bony finger but uttering not a word.
They could easily represent "three aspects of a single therapist," says Warres, or at least a range of therapeutic approaches: variously insistent and passive, chatty and silent, gentle and stern.
Like the typical patient, Scrooge shows a spectrum of responses. He resists, acquiesces, actively participates. He finds the process a torture, he finds it liberating. He's angry and grateful with the ghosts. The man who began the process considering Marley a "humbug" ends up celebrating on Christmas morning: "The Spirits have done it all in one night. They can do anything they like. Of course they can."
Such life-changing work accomplished in such a short time would surely cheer the heart of any managed-care bean-counter. Warres told his audience that he had submitted the Case of Ebenezer S. for review to a "Dr. Les Kost" of Seamless Behavioral Health. Kost wrote back, he said, delighted to find that the case provided "scientific evidence to justify our new policy of restricting all psychotherapy to three sessions at a maximum."
Note the turned tables. Compelled by economics and too much faith in the quick pharmaceutical fix, the contemporary practitioner plays the role of an unreformed Scrooge. Charles Dickens may not have invented psychotherapy, Warres says, but he appears to have seen it coming.