Theoretical Considerations of the Birth Trauma

Fear is the reaction to danger. However, one can not reject the idea that it is connected with the nature of danger if the fear affect can force an exceptional situation in the psychic economy. But dangers are in general human and the same for all individuals; what we need and do not have at our disposal is a factor which makes intelligible to us the selection of the individual who can subject the fear affect despite its strangeness to the normal psychic management, or determines who must fail at this task. I see before me two efforts to uncover such a factor; it is comprehensible that all such efforts may expect a sympathetic reception for they promise redress for a tormenting need. Both of these attempts supplement each other because they attack the problem from opposite sides. The first was undertaken more than ten years ago by Alfred Adler, who maintained---reduced to its inmost nucleus---that in those individuals who are unable to master the task imposed by danger, their organ inferiority makes the difficulties too great. If the maxim _simplex sigillum veri_ is true one must greet such a solution as a redemption. But on the contrary the criticism of the past decade has proven conclusively the complete insufficiency of this explanation, which moreover puts itself outside of the entire superstructure of facts uncovered by psychoanalysis.

The second essay was undertaken in 1923 by Otto Rank in his book "The Birth Trauma." It would be unjust to place it on a par with Adler's effort save in the connection made above, for it rests on the foundation of psychoanalysis and continues its course of thought and should be recognized as a legitimate effort toward the solution of the analytic problem. In the relation given between the individual and danger, Rank diverts from the organ weakness of the individual and towards the variable intensity of the danger. Birth is the first danger situation and the economic disturbance produced by it is the prototype of the fear reaction. We have already followed the line of development which unites this first danger situation and fear condition with all later ones and have seen that all preserve something in common, for all in a certain sense indicate separation from the mother---at first only in a biological respect, later in the sense of the direct loss of the object, and finally in the indirect loss of the same. The discovery of this great association is the undisputed service of the Rank construction. Now the birth situation concerns the individual with a difference in intensity; with the severity of the trauma there is a variation in the violence of the fear reaction and, according to Rank, the initial volume of the fear development should determine whether the individual will or will not acquire mastery---whether he is to become normal or neurotic. The criticism of the whole Rank conception is not our task here---only the test of its utility for the solution of our problem. The formula of Rank's that neurotics are those who cannot react off the over-strong birth trauma is in theory vulnerable in a high degree. We do not know just what is meant by the reacting off of a trauma. If understood literally one comes to the untenable conclusion that the neurotic is the nearer well the more frequently and intensely he can reproduce the fear affect. Because of this contradiction with reality I have in due course given up the theory of reacting off which plays so great a rôle in catharsis. Emphasis of the variable strength of the birth trauma leaves no room for justifiable etiological claim of the hereditary constitution. This is, of course, an organic factor which behaves toward the constitution as a contingency, and is itself dependent on many influences which may be called contingent, as from timely assistance in labor.

The Rank doctrine has left constitutional as well as phylogenetic factors out of consideration altogether. If one will prepare space for the significance of the constitution, perhaps through a modification of the same, it would be much more to the point to know how prolifically the individual reacts to the variable intensity of the birth trauma. Thus one deprives the theory of its significance and restricts the newly introduced factor to an accessory rôle. The decision as to the fate of the neurosis lies, then, in another and again an unknown territory.

The fact that mankind has the birth process in common with other mammals and at the same time has the preference of a particular disposition to neuroses over the other mammals will hardly attune favorably with the Rank theory. The chief objection, however, remains that it is in the air and does not rest on an assured foundation. There have been no good studies as to whether severe and protracted labor coincides unmistakably with the development of neurosis and if children thus born show the phenomena of early infantile fears longer or more strongly than others. If one could show that precipitate labors which were easy for the mother might possibly possess the significance of severe traumas for the child, the demand would still remain that labors which lead to asphyxia must allow the alleged consequences to be recognized with certainty. It appears an advantage to the Rank etiology that it supplies a factor which is accessible to testing with the material of experiment, but as long as such a trial has never yet been actually undertaken it is impossible to judge of the value.

On the other hand I cannot join in the opinion that the Rank theory opposes the etiological significance of the sexual impulse hitherto recognized in psychoanalysis; for this refers only to the relation of the individual to the danger situation and fortunately leaves open the supposition that whoever cannot master the original dangers must also fail in the later developing sexual situations and thereby be forced into a neurosis.

I therefore do not believe that the Rank essay has brought to us the answer to the question of the foundation of the neurosis and I think it cannot yet be decided, no matter how great the contribution to the subject it may comprise. If the investigations over the influence of severe labor on the disposition to neurosis fall out negative, this contribution must be valued but slightly. It is to be lamented that the need for a tangible and uniform final cause of nervousness still remains unsatisfied. The ideal case after which the physician probably longs to-day should be the bacillus which can be isolated and cultured pure and of which inoculation into a given individual will cause the disease in question. Or, to be less fanciful, the presentation of a chemical substance the exhibition of which may both produce and abolish definite neuroses. But probability speaks against such solutions of the problem.

Psychoanalysis leads to less simple and less satisfactory information. I have here to repeat only what has long been known and have nothing new to add. If the ego succeeds in protecting itself against a dangerous impulse, for example, by the process of repression, it has indeed inhibited and injured this portion of the It but has at the same time given up a portion of its own independence and renounced some of its own sovereignty. This follows from the nature of repression which is an attempt at flight. The repressed content is now "free as a bird," excluded from the great organization of the ego, subjected only to the laws that reign in the realm of the unconscious. If the danger situation alters, so that the ego has no motif to repel a new impulse analogous to the repressed content, the consequences of the ego limitation are obvious. The course of the more recent prompting completes itself under the influence of automatism---I prefer to say of the compulsion to repetition---it wanders the same way as the former repressed content as if the conquered danger situation still persisted. The fixing factor of the repression is therefore the repetition compulsion of the unconscious It which normally is abolished only by the freely mobile function of the ego. Now it may at times succeed to the ego to recapture the repression which it itself had arranged and to regain its influence over the prompting and to direct the course of the new prompting in the direction of the altered danger situation. The fact is that this so often fails of success, that it cannot make its repressions regressive. Quantitative relations may be authoritative for the outcome of this combat and in many cases we gain the impression that the decision is compulsive; the regressive attraction of the repressed instinct and the strength of repression are so great that the more recent prompting can only follow the repetition compulsion. In other cases we perceive the contribution of another play of force; the attraction of the repressed prototype is fortified through repulsion from the side of the actual difficulties which are opposed by the different course of the more recent promptings.

That this is the origin of the investment of the repression and the maintenance of the no longer actual danger situation, finds its proof in the modest although theoretically hardly overestimable fact of analytic therapy. If we furnish aid to the ego in the analysis which will enable it to abolish its repressions it regains power over the repressed It and can allow the impulses to run their course as if the old danger situations no longer existed. What we thus attain is in harmony with other powers of our medical performance. As a rule our therapy must be satisfied with bringing about the good result more rapidly, more trustworthily and with little outlay, which under favorable conditions might have come about spontaneously.

The previous considerations teach us that there are quantitative relations which are not directly visible, comprehended only through inference, which decide whether the old danger situation is held fast, whether the repressions of the ego are maintained, and whether or not there is a continuation of the child neuroses. Of the factors which take part in the causation of the neuroses, which have created the conditions under which the psychic forces measure themselves with another, there are three which become conspicuous for our comprehension---one biologic, one phylogenetic and one purely psychologic. The first mentioned is the long drawn out helplessness of the small human child. The intrauterine existence of man seems relatively shorter than that of most of the animals and he is sent into the world less apt. As a result the influence of the external world is strengthened, the differentiation of the ego from the It is precociously promoted, the dangers of the outer world are increased in importance and the value of the object, which can alone protect from these dangers and replace the lost intrauterine life, is greatly enhanced. This biologic factor prepares the first danger situation and creates the need to be loved which will never more leave the human subject.

The second, phylogenetic, factor is only inferred by us; a very notable fact of libido development has forced us to assume it. We find that the sexual life of mankind is not developed steadily from beginning to maturity, as in most of the nearest related animals, but that after an early bloom up to the fifth year it experiences an energetic interruption, after which it again becomes prominent with puberty and annexes itself to the infantile fractions. We think that something important to the destiny of mankind must have happened which this interruption of sexual development has left behind as a historical precipitate. The pathogenic significance of this factor is apparent from the fact that most of the impulse claims of this infantile sexuality are treated by the ego as dangers and repulsed, so that the later sexual stirrings of puberty, which should be normal to the ego, are in danger of subjugation to the attraction of infantile prototypes and follow these in repression. Here we abut against the most direct etiology of the neuroses. It is noteworthy that the early contact with the claims of sexuality works upon the ego in the same manner as precocious contact with the external world.

The third or psychologic factor is to be found in the incompleteness of our psychic apparatus which is connected with its differentiation into the ego and It, hence in the last analysis it goes back to the influence of the external world. Through regard for the dangers of reality the ego is forced to oppose itself against certain promptings of the It and to treat them as dangers. The ego, however, cannot defend itself against inner promptings so efficaciously as against a fragment of alien reality. Itself intimately connected with the It, it can only defend itself against the danger of the impulse while contracting its own organization and allows itself to fall into symptom formation as a substitute for its injury of the impulse. If the crowding of the repulsed impulse is then renewed there result for the ego all of the difficulties which we know as the neurotic affection.

I must believe that our insight into the nature and causation of the neuroses cannot go further at present.