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The Birth Trauma: A Critique

ANXIETY is the reaction to danger. One cannot escape
the thought, indeed, that the very nature of danger has
a bearing upon the fact that the affect of anxiety is able
to command pride of place in the mental economy. But
the dangers in question are those common to all man-
kind; they are the same for everybody; so that what we
need and do not have at our disposal is some factor which
shall enable us to understand the basis of selection of
those individuals who are able to subject the affect of
anxiety, despite its singularity, to normal psychic con-
trol, or which on the other hand determines those who
must prove unequal to this task. I have in mind two at-
tempts which have been made to discover such a factor;
and certainly any such attempt may reasonably expect
a sympathetic reception, since it promises to remedy a
crying need. The two attempts I refer to supplement each
other in that they attack the problem from opposite ends.
The first was undertaken more than ten years ago¹ by
Alfred Adler; his thesis, in a nutshell, is that those in-
dividuals fail to solve the problem which danger imposes
in whom an organ inferiority makes such a task too dif-
ficult of accomplishment. Now if it were true that sim-
plex sigillum veri, one would welcome such a solution
as this as a very salvation. On the contrary, however, the
consensus of criticism during the decade just passed has

¹Now more than twenty years ago.—Translator’s Note.

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amply demonstrated the complete inadequacy of this
explanation, which, moreover, totally disregards the
wealth of facts discovered by psychoanalysis.

The second attempt was undertaken by Otto Rank in
1923 in his book, The Trauma of Birth. It would be
invidious to compare this attempt with Adler’s in any
other respect than the single one here emphasized, for
Rank’s rests on a psychoanalytic foundation, pursues psy-
choanalytic trends of thought, and is to be regarded as
a legitimate effort towards the solution of analytic prob-
lems. In the relation between the individual and danger
Rank assigns less importance to organ inferiority in the
individual and emphasizes rather the varying intensity
of the danger. The process of birth constitutes the first
danger situation, the economic upheaval which birth en-
tails becomes the prototype of the anxiety reaction; we
have already followed out the line of development which
connects this first danger, this first anxiety-occasioning
situation, with all subsequent ones; and in so doing we
saw that they all retain something in common in that all
of them signify in some sense a separation from the
mother, at first only in a biological respect, then in the
sense of a direct object loss, and later of an object loss
mediated in indirect ways. The revealing of this sequence
of events is an undisputed merit of the Rankian con-
struction. Now the trauma of birth affects different indi-
viduals with differing intensity, the intensity of the anx-
iety reaction varies with the severity of the trauma, and,
according to Rank, it is supposed to depend upon the
degree to which this initial development of anxiety takes
place whether the individual ever succeeds in gaining

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control over it, whether he becomes a neurotic or a nor-
mal person.

The detailed criticism of Rank’s thesis is not our task,
but merely its examination from the standpoint of its
serviceability in the solution of our problem. Rank’s for-
mula, that those persons become neurotic who on ac-
count of the severity of the birth trauma have never suc-
ceeded in abreacting it completely, is theoretically open
to the greatest possible doubt. It is not entirely clear what
is meant by the abreacting of the trauma. If it is taken
literally, one arrives at the quite untenable conclusion
that the neurotic approaches more and more closely to a
state of health the more frequently and the more inten-
sively he reproduces the affect of anxiety. It was on the
ground of this very nonconformity with reality that I
abandoned, indeed, the theory of abreaction, the theory
which played so large a part in catharsis. The emphasis
upon the varying severity of the birth trauma leaves no
room for the legitimate ætiological claim of constitu-
tional factors. This severity is an organic factor, certainly,
one which compared with constitution is a chance factor,
and is itself dependent upon many influences which are
to be termed accidental, such as for example timely ob-
stetrical assistance. But the Rankian theory has left con-
stitutional as well as phylogenetic factors entirely out of
account. If one were to allow for the importance of a
constitutional factor, such as via the modification that it
would depend much more upon how extensively the in-
dividual reacts to the variable severity of the birth
trauma, one would deprive the theory of meaning and
have reduced the new factor which Rank has introduced

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to a subordinate rôle. That which determines whether
or not neurosis is the outcome lies, then, in some other
area, and once again in an unknown one.

The fact that the human being shares the birth process
with other mammals, whereas a particular disposition to
neurosis is the special privilege which he alone possesses,
hardly speaks very strongly in favor of the Rankian
theory. The principal objection to be raised against it,
however, remains the fact that it hangs in mid-
air, instead of being based upon verified observation. For no
trustworthy investigation has ever been carried out to
determine whether difficult and protracted birth is cor-
related in indisputable fashion with the development
of neurosis–indeed, whether children whose birth has
been of this character manifest even the nervousness of
earliest infancy for a longer period or more intensely
than others. If the assertion is made that precipitate
births, those easy for the mother, may possibly have for
the child the significance of a severe trauma, then a for-
tiori it would certainly be necessary that births resulting
in asphyxia should produce beyond any doubt the conse-
quences alleged. It seems an advantage of the Rankian
ætiology that it postulates a factor capable of being
checked empirically; but as long as such a check has never
actually been undertaken, it is impossible to estimate its
real value.

On the other hand, I cannot share the view that the
Rankian theory controverts the ætiological importance
of the sexual instincts as this has so far been recognized
in psychoanalysis; for the theory refers only to the be-
havior of the individual towards the danger situation,
and leaves the matter open whether the person who was

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unable to overcome the initial dangers which beset him
will necessarily fail in the situations of sexual danger of
later occurrence and thereby be forced into neurosis.

All in all, then, I do not believe that Rank’s endeavor
has supplied us with the solution of the problem of the
fundamental basis of neurosis, and I think that it cannot
yet be decided how large a contribution to the solution
of the problem it actually makes. If investigation of the
influence of difficult birth upon the disposition to neuro-
sis yields only a negative result, its contribution will be
slight indeed. I am very much afraid that the need for a
tangible and simple “ultimate cause” of neurosis is
doomed to remain ungratified. The ideal possibility, for
which probably even today the physician longs, would
be that of a bacillus which can be isolated and grown in
pure culture and the inoculation of which produces the
identical effect in every individual; or, somewhat less
fantastically, the evolving of chemical substances, the ad-
ministration of which produces a given neurosis or abol-
ishes it. But probability is hardly on the side of such
solutions of the problem.

Psychoanalysis yields less simple, less satisfying intelli-
gence. I have here to repeat only what has long been
familiar, adding nothing new. When the ego has suc-
ceeded in defending itself against a dangerous instinctual
impulse, as for example by the mechanism of repression,
it has inhibited and inflicted damage upon that portion
of the id but has at the same time also given it a bit of
independence and renounced a bit of its own sovereignty.
This follows from the nature of repression, which is, at
bottom, an attempt at flight. The repressed material is
now “outlawed,” excluded from the great organization

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of the ego, subject only to the laws which prevail in the
domain of the unconscious. If now the danger situation
is altered, so that the ego is without incentive to defend
itself against a newly arisen instinctual impulse analo-
gous to the one which has been repressed, the conse-
quences of this limitation of the ego’s sovereignty become
manifest. The new instinct pursues its course in auto-
matic fashion–I should prefer to say, under the influ-
ence of the repetition compulsion; it follows the same
path as did the instinct which had previously been re-
pressed, as though the successfully surmounted danger
situation were still in existence. The fixating factor in
repression is thus the repetition compulsion of the un-
conscious id, which normally is put an end to only
through freely mobile ego-functioning. Now the ego may
occasionally succeed in making a breach in the barriers
of repression which it has itself set up, in reacquiring its
influence over the instinctual impulse and in guiding
the course of the new instinctual impulse in accordance
with the altered danger situation. But as a matter of fact
the ego often fails in this and is unable to undo its repres-
sions. Quantitative factors may play a deciding part in
the outcome of this struggle. In many cases we have the
impression that the outcome is a compulsory one; the
regressive attraction exerted by the repressed impulse
and the force of the repression are so great that the new
impulse can only follow out the repetition compulsion.
In other cases we perceive the contribution of another
set of forces; the attraction exerted by the repressed pro-
totype is reënforced by the repulsion exerted by reality
obstacles which oppose any other discharge of the newly
arisen instinctual impulse.

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That this is the course of events in the fixation of
repression, and in the retention of danger situations no
longer current, receives its proof from the fact of analytic
therapy, a fact modest enough in itself but theoretically
scarcely to be overestimated. When in analysis we render
the ego assistance enabling it to undo its repressions, the
ego regains its power over the repressed id and can so
steer the course of the instinctual impulses as if the old
danger situations no longer existed. What we achieve in
this way is in complete harmony with what we accom-
plish in other spheres of medical activity. As a rule our
treatment has to be satisfied with bringing about more
rapidly, more certainly and with less trouble the satis-
factory outcome which under favorable conditions would
have resulted spontaneously.

The foregoing considerations tell us that there are
quantitative elements not directly evident but to be ap-
prehended only a posteriori, which decide the question
whether the old danger situations are adhered to, whether
the repressions effected by the ego are preserved, whether
childhood neuroses are carried over into later life, or not.
Of the factors which are contributory in the causation of
neurosis, the factors which have created the conditions
under which the forces of the psyche contend among
themselves, there are three which present themselves for
our consideration—a biological, a phylogenetic, and a
purely psychological factor. The biological factor is the
protracted helplessness and dependence of the young of
the human species. The intrauterine life of the human
being seems to be relatively abbreviated as compared
with that of the majority of animals; the human infant
is sent into the world more unfinished than the young of

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the latter. For this reason the influence of the external
environment is intensified, the differentiating of the ego
from the id is promoted very early, the dangers which the
environment presents are increased in importance, and
the value attached to the object who alone can offer pro-
tection against these dangers and effect a substitution
for the intrauterine life which has been lost, is enor-
mously augmented. This biological factor of helplessness
thus brings into being the first situations of danger and
creates the need to be loved which the human being is
destined never to renounce.

The second, the phylogenetic, factor is one which we
merely infer; but a very remarkable fact of libido de-
velopment has compelled us to assume its existence. We
find that the sexual life of the human being does not
develop in progressive fashion from incipience to matur- ity, as in the case of most of the closely related animals,
but that it suffers an abrupt interruption after an initial
early florescence extending to about the fifth year, after
which it commences anew with puberty, dovetailing, as
it were, with the tendencies of the infantile period. We
believe that something momentous to the destinies of the
human species must have taken place which has left be-
hind as an historical precipitate this interruption of sex-
ual development. The pathogenic importance of this
phenomenon accrues from the fact that most of the in-
stinctual demands of this infantile sexuality are treated
as dangers and guarded against by the ego, so that the
sexual impulses of puberty, which should be ego-compat-
ible, are in danger of succumbing to the attraction ex-
erted by their infantile prototypes and of following them
into repression. It is here that we come upon the most

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definite ætiology of the neuroses. It is note-
worthy that early contact with the demands of sexuality has the same
effect upon the ego as premature contact with the en-
vironment.

The third or psychological factor is to be found in an
imperfection of our psychic apparatus which is connected
with its differentiation into ego and id and hence which
is traceable also, in the last analysis, to the influence of
the environment. By reason of the dangers which reality
offers, the ego is compelled to adopt an attitude of de-
fense towards certain instinctual impulses in the id, to
treat them as dangers. But the ego cannot protect itself
against internal instinctual dangers so effectively as
against a piece of reality which is strange to it. Itself inti-
mately connected with the id, the ego is able to stave off
an instinctual danger only by putting restrictions upon
its own organization and by tolerating symptom forma-
tion as a substitute for its crippling of the instinct. If then
the press of the repudiated instinct is renewed, there
result for the ego all the difficulties which we know as
neurotic suffering.

Further than this, I must believe, our insight into the
nature and causation of neurosis has not at the present
time progressed.