Introduction:
Now that over 60 years have passed since their liberation, the associations and assumptions about Holocaust survivors have evolved. It is unusual to find a cohort that shared such an intense social, historical, moral and personal crisis. Ever since their liberation in 1945, research scientists and clinicians have been studying Holocaust survivors in order to understand and treat them in the aftermath of this genocide.
This paper discusses the evolution of this understanding and since the literature on Holocaust survivors is confined to the period post 1945, there is a finite amount of material. The literature discussed in this article was accessed online through the Ovid, Scholars Portal and Proquest Research Library databases, while older articles and books not sourced online or out of print were hand sourced and acquired from the collections of various Toronto Jewish institutions and the personal collections of Holocaust scholars in Israel, the United States and Canada. Another excellent resource was Krell and Sherman’s (1997) Bibliographic Review of “Medical and Psychological Effects of Concentration Camps on Holocaust Survivors”, where they list 2,461 articles on this topic alone and included both research and popular articles.
Journal articles and reports selected for review were those cited and discussed frequently in several articles, those that were deemed relevant to the current cohort of survivors, those with historical merit, those that examined trauma in Holocaust survivors across their life course and more recently those that considered survivors in a gerontological context. This review is not intended to represent the entire body of literature but serve as an overview of relevant material for interested readers.
Early Considerations:
Safford (1995) defines a survivor of the Holocaust as anyone who experienced the work or death camps, or was hidden throughout the war in occupied territory, exposed daily to death, starvation, extreme violence and the loss of family. This definition also includes Jews who were members of resistant fighter groups, those who hidden or concealed their identity and tried to pass as non-Jewish and those who left Europe before 1939 but lost their family members and friends due to death caused by Nazi persecution.
This is the definition most commonly in use (AMCHA 2005) and one that recognizes the emphasis is not on defining a hierarchy of pain and suffering but rather on recognizing individuals’ experience of extreme loss and trauma. At the end of World War II, over six million had perished. In 1948, The International Refugee Organization was formed to coordinate the care of over 643,000 survivors in displaced persons camps across Europe (USHMM, retrieved 2006). Others managed to leave Europe or found independent shelter.
During the first four decades following liberation, the narratives, the resilience, the challenges and the coping mechanisms of most survivors were not fully reported or even considered (Lomranz 1990; Grauer 1999). Weiss and Durst (1994) make note of one of the earliest known reports on the survivors. In 1946, a Dutch psychiatrist, described the “difficulty survivors had in everything relating to expressing anger or feelings that arose as a result of their wartime experience” and that “this phenomenon would slow the process of uncovering the client’s inner self and would make his treatment more difficult” (Tas, cited in Weiss and Durst 1994, p.85).
In 1948, the papers on traumatized survivors ( Friedman 1948; Boder 1949) first emerged in the literature and they are exploratory and tentative.
“In the immediate post-war period, interviews with a psychological orientation were rare. Interviews were conducted primarily for the purpose of relocation, physical assistance, evidence for war crimes, and also for the historical record” (Krell and Sherman 1997, p.7).
Following Liberation and relocation, as the Holocaust survivors began to tell of their experiences, it became apparent that healthcare professionals would have to develop a new frame of reference for responding to them. In the early 1950s, psychiatrists working with the survivors felt they would have shortened life spans and suffer permanent residual psychological damage due to the extent of physical and emotional abuse endured during the war (Niederland 1964; Krystal 1968; Cohen 1977). During this decade, another cohort studied consisted of those survivors who applied for restitution funds. In order to qualify, they had to prove some sort of residual medical or psychiatric disability (Bergman and Jucovy 1982; Krell 1990) and were often placed in a position to emphasize, exaggerate or reveal specific vulnerabilities in exchange for payment. Called “Wiedergutmachung,” meaning “to make good again,” the money came from the German government and divided the survivor community on the moral issues of accepting it. Not only did survivors have to defend their right to apply to German authorities, they also often had to defend their receipt of these funds to their fellow survivors.
More comprehensive research and scholarly writings on the Holocaust survivors did not appear in significant numbers until the early 1960s. By then most survivors had relocated and settled into new countries and new lives with varying levels of adaptability. Psychiatrists, psychologists and social scientists began following their post War lives with growing interest.
Questioning the Literature:
There was little critical response to the early literature until the 1960s, when it became apparent that these early observations and resultant studies, in many cases, pathologized the Holocaust survivors (Niederland 1964; Krystal 1981; Steinitz 1981; Steinitz 1982) and did not paint an accurate picture of how the majority integrated their traumatic experiences.
Krystal (1968) questioned whether anyone could survive the devastating trauma of the Nazi Holocaust. Years later, he reviews this early work and discusses how most healthcare providers that examined survivors soon after liberation were seeing the minority who were incapacitated by poor health and had no choice but to seek medical or psychiatric help (Krystal 1981). As subjects of study, psychiatric patients with acute problems and the recipients of these restitution payments generated conclusions about the larger survivor population. The majority of survivors who were able to avoid medical, governmental or bureaucratic questioning did their best to do so (Danieli, 1981). In hindsight, considering the minority of Holocaust survivors studied, the researchers were not studying either a representative or particularly forthcoming population sample–yet for almost two decades this literature informed the understanding of the entire survivor population.
Much of the social work literature on survivors who are older adults is based on case studies and commentary (Cohen 1991; David, 1998; Giberovitch, 1999; Zilberfein and Eskin, 1992) , building on Rosenbloom’s (1985 ) early work. Within the context of the time frame in which she wrote, the survivors were introduced as multidimensional individuals, as opposed to the generalizations of individuals described by the medical profession in the earlier longitudinal studies.
An Israeli social worker, Harel (1995), also identifies early methodological problems, pointing out that many of the studies rely on psychoanalytic literature and generalize their findings to the larger population even though they have not considered psychosocial, behavioural and contextual factors. Early studies on Holocaust survivors were generalizing on non- representative, generally small samples and drawing conclusions based on questionable criteria (Berger 1975, Krell, 1997, Solkoff, 1981). In 1975, a critique of post-war treatment approaches to survivors (Berger 1975) showed that studies dealing with the psychotherapy of survivors are rare, giving as a reason that the survivors, as a rule, did not seek out psychotherapy. Berger also pointed out that existing treatment modalities of
“traumatic neurosis had never before been tested by a trauma so massive and extensive…. Rather than squeezing our findings into established theoretical pigeon holes, our theories about psychologic sequelae of trauma need revamping in order to accommodate the new findings” (Berger 1975) (p.241).
Berger further states that while this is “alien ground for the psychiatrist, it is an area in which cultural factors may impinge upon and reinforce individual psychopathology” (p.249).
Solkoff (1981) also pointed out how the studies of survivors to date demonstrate “serious conceptual and methodological limitations” (Solkoff 1981) and challenged their generalizations. In 1973 Barocas and Barocas writes “It is difficult to imagine a person emerging from such a set of experiences without sustaining psychic scars that may become firmly entrenched in his behavioral patterns” (1973 p.820). Cath (1981) states “But there is danger in over generalizing from them or in placing a one-sided emphasis of illness without paying attention to the overall human potential for adaptability and recovery in other survivors” (p. 159) (Cath 1981). This became a theme for subsequent research.
By the 1990s, with the benefit of time and subsequent studies, the problems with the early literature are well documented and many of the erroneous conclusions re-evaluated (Danieli 1994; Wardi 1994; Felsen 1998; Waxman 2000). Later research (Wiseman, Yam et al. 2002; Sagi-Schwartz, Grossmann et al. 2003; Van Ijzendoorn, Bakermans-Kranenburg et al. 2003) also includes more qualitative studies that reach beyond the clinical samples to the general survivor population and by virtue of their date begin to consider how aging impacts on resilience and coping.
Aging Survivors:
Looking back on the studies of Holocaust survivors over the decades, there are two paradigms to consider in their post war lives. The first, as discussed, was steeped in pathology and occurred in the decades immediately following liberation. Early studies focused on patients in mental health settings and descriptive words such as “survivor syndrome” (Niederland 1964), guilt, anxiety, anhedonia and abandonment were common (Krystal 1968; Berger 1975; Cohen 1977; Danieli 1981). The second demonstrates a marked shift in the literature in the past two decades, as the survivors aged and where words like resilience, strength, mastery, autonomy and integration are now used in describing their psychological states (Bar-Tur 2000; Lomranz 2005; Suedfeld, Soriano et al. 2005).
Bar-Tur and Levy-Schiff (2000) discuss the “losses and gains associated with inner processes of separation-individuation and the role they play in the adjustment of the elderly” (p.265) and discuss the importance of their development across the life span. In 1987, forty years after liberation, in a discussion of the changing circumstances of survivors’ responses to trauma and the different approaches, Dasberg (1987) reviews pertinent studies and explores reasons for change. He credits the changing generations, social changes, developmental changes, new services, the advent of new stresses and more empirical studies using random samples of the larger survivor community. At that time, the majority of survivors would have been in their sixties or seventies. There are still few studies that look specifically at the impact of early life trauma on aging and consider the prevalence of Post Traumatic Stress in older survivors (Krystal 1981; Grauer 1999; Joffe 2003). Joffe et al (2003) in the first systematic study of survivors in Australia concluded that, “the psychological effects of massive trauma are severe and enduring” (p.46).
Danieli (1994) describes how “many survivors experience the normal phenomena of old age as a recapitulation of Holocaust experiences” (p.3). Schnurr (1994) indicates that case reports “suggest that retirement-induced stress may worsen PTSD or even lead to PTSD in asymptomatic combat veterans” (p.1). During this critical life stage, traumatic losses of the past may colour and impose on losses of the present. Even many years after release, escape or liberation, apparently successful relocation and social re-integration, war survivors’ early life experiences may inform, underline and cast a shadow over all aspects of their lives (David 1998). “Little empirical work has been performed evaluating the demographics, clinical presentation, assessment, diagnosis and management of Post Traumatic Stress Disorder (PTSD) in the elderly” (Cook 2001 p.1).
In her work with elderly Holocaust survivors in England, Hassan (2003) emphasizes that “…the only therapy which is of any use to a severely traumatized person is the one in which the person asking for help feels helped” (p. 138). As one of the small group of authors considering aging survivors in the context of a life course perspective, Hassan states that
“The rebuilding of survivors’ lives was, for some, only a façade which cracked and fell apart, unable to sustain itself under renewed attack from current traumatic experiences. The depth of despair and hopelessness which resurfaced brought death’s countenance sharply into focus. The will to live and survive as natural death drew nearer seemed to fade in the over-whelming darkness that overshadowed their lives” (p. 118).
Hassan also recognizes that traditional models of psychotherapeutic interventions are not always appropriate for aging survivors and gives many case studies where creative and individualized approaches are the only effective option. The paradox is that while war survivors have such individual responses to their specific trauma, they still share many unique commonalities (David 1998). Danieli (1994) states
“It is, therefore, both a clinical and a social policy task to incorporate a multi-dimensional, interdisciplinary integrative framework in designing longitudinal intervention, postvention and prevention programs (Danieli, 1994, p.22).
Lomranz (1990) also calls for comparative and integrative studies, stating
“Stress and family researchers, life-span developmentalists, and gerontologists should cooperate in interdisciplinary, longitudinal research to advance theory and methodology and to develop appropriate interventions programs in this area” (p.119).
In old age, when there is a focus on healthcare and medical interventions, an approach to caring for trauma survivors requires different approaches to care. Bloom (1997) speaks of “creating sanctuary” (p.115). Herman (1992) describes “safe environments” (p.164) and Hassan (2003) talks of the importance of “connecting two worlds” (p225). Practice with older war survivors as described by David et al (2003) demonstrates that an environment that recognizes and responds to early life trauma with a sensitive and conscious approach lessens anxiety.
Kahana (1989) discusses how “Traditional approaches to research on Holocaust survivors have generally sought to identify physical health problems and psychopathology among those who have endured extreme stress” (p. 203). Lifton (1979) underlines this by concluding that the survivors life review is challenged by “psychic numbing, desymbolization, deformation” (p. 69), further compounding the challenges in integrating and coping with mourning and grieving. In a mixed-method study aimed at bringing “both a more comprehensive and humanistic perspective to understanding adaptation of elderly survivors of the Holocaust” (p.203), Krell and Sherman (1997) discuss the how the “psychiatric literature has reflected badly on the survivor and suffers from over-generalization” (p. 27). Kahana (1989) found differences between survivors and the comparison group in “terms of physical health, psychiatric symptomatology and social functioning” (p.203).
As survivors’ issues evolve with their respective mental and physical maturation, there is an important role for ongoing study. Firstly, the early literature must be balanced with more inclusive studies and secondly, the issues of a much older cohort must be examined. If they have managed to reach old age, survivors and their families are now dealing with the range of changes and adjustments that often accompany aging. Relocation, chronic or acute illness, retirement, loss of a spouse and other life course events associated with aging may have different meanings for different survivors (David, 1998). Loss and bereavement are thematic in old age and aspects of Holocaust survivors’ bereavement, loss and mourning were discussed by several authors in detail (Grauer 1999, Eitinger 1973, Danieli 1981) but more often as an outcome of trauma rather than as an issue that focused on understanding the impact of massive losses within the context of bereavement theory
Lomranz (1990) discusses how, in the context of the long-term adaptation of Holocaust survivors, that “the field lacks theoretical models and conceptualizations.” (p.115) He suggests that, “Ironically, it appears that for some survivors, the Holocaust experience helped prepare them to respond appropriately to future losses.” (p.115) Lomranz calls for research that is “life-span oriented, developmental, longitudinal, interactive and multivariate… (p.117) in order to develop appropriate intervention programs in this area.”(p.119)
The life course perspective examines “how aging is related to and shaped by social contexts, cultural leanings, and social structural location and how time, period, and cohort shape the aging process for individuals, as well as social groups.” (p.79, Bengston 1997) Not considering Holocaust survivors within the context of their life course excludes an understanding of how their individual strengths, vulnerabilities and coping capacities contributed to the integration of their Holocaust-related trauma and their subsequent challenges and accomplishments. In a mixed method study using a narrative approach, (De Vries, Suedfeld et al. 2005), the authors explore the role of the Holocaust in the life stories of survivors. They found that an examination of individuals’ life stories and how they are constructed demonstrates that the interpretation of life is more than the analysis of past events and circumstances. It is an understanding of one’s whole and entire life
Aging survivors are a group of individuals who share the Holocaust as a common critical turning point in their lives. This was an external event that had major and different impacts on those who survived. Their commonality today is how that turning point influenced their subsequent life course, and how those effects play a part in the aging process. Krystal, (1981) states that, “The trouble is that in this process of reviewing one’s life, as the memories are restored to the self-representation and are owned up to (in other words, in the process of the return of the repressed) the individual experiences pain” (p. 184). In discussing the capacity for survivors to achieve “integrity in aging” Krystal (p.187) further states that survivors must be able to “work through their losses and problems of guilt and shame” in order to reach this integrity.
Whether it is called a life review, a narrative, bearing witness or reminiscence, reconciliation and resolution of one’s life events is considered a developmental stage for health in older adults in preparation for end of life (Erikson 1950, Danieli 1988). Erikson (1950) described ego integrity as the final goal of individual development. Greenspan (1998) responds to the individual and Lomranz (1990) considers individual development and states that “Coping with trauma involves reorganizing cognitive maps that were ruptured by the catastrophe proposes a multidimensional, integrative framework that includes the relationship between “developmental stages and historical and cultural contexts, on the one hand, and the patterns of traumatic stress on the other” (p.99).
His research, through examining survivors’ narratives, looks at how their coping strategies have ameliorated the long-term effects of post-traumatic stress. He points out “that there appears to be a contrast between required emotional demands in middle age, that were structured in the traumatic and posttraumatic periods, and those of old age” (p.100).
Davidson (1992) identifies seven main factors that “determine the long term effects of the Holocaust trauma in the life cycle of the survivors” (p.57). They range from pre-Holocaust life circumstances, personalities, ages and families, through physical illnesses during the war and post-liberation experiences including family strengths and supports. Davidson recognizes that his earlier conclusions were based on psychopathology and later expands his understanding to include the “normal spectrum of life functioning of survivors who do not present themselves as patients” (p.58).
Within a life course theoretical perspective, the survivors experienced a cohort effect, as their experience and memory of World War II is unique and only shared with others who were targeted for annihilation by the Nazis. Traditional psychoanalytic developmental theory (Lifton 1979; Danieli 1981; Krystal 1981; Suedfeld, Soriano et al. 2005) indicates major challenges for aging survivors in the early studies, but a larger aging cohort and a broader theoretical approach within the context of the life course perspective demonstrates more health and resilience than initially reported. (Suedfeld, Soriano et al. 2005, Kahana et al, 2005)
Throughout any consideration of a practice model in supporting aging trauma survivors is the necessity to integrate research and education. The literature and the clinical evidence indicate that safe havens and empowering environments are the most effective supports for aging (Herman 1992; David and Pelly 2003; Hassan 2003). It is a unique opportunity to blend theory with practice that will benefit service providers, the community and ultimately aging Holocaust survivors. Now that they are dealing with the final chapter of their lives; there is much to revisit, reconsider and redefine when discussing the impact of the Holocaust within a life course perspective. A framework that encompasses a reflective overview of their lives, their experiences and their narratives would provide the foundation of a more holistic and comprehensive understanding of aging survivors.
Chronological Evolution of the Literature Displaying Parallels to the Life Course of Older Holocaust Survivors1960s
1970s
Survivors establishing themselves in adopted countries and creating new families. Raising and supporting families
Creation of ‘clubs’ i.e. mutual aid and benefit groups in communities around the world
1990s
Survivors are late middle age and according to current longevity expectations, considered ‘old.’ Beginning to bear witness outside own communities.
Cohort experiences major lifestyle changes: retirement, grandchildren etc. Many more survivor narratives emerging. Cohort beginning to die due to natural causes.
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