“And I was hungry
And for love
I was hungry
To feel what it is like to belong to someone
I was hungry”
The poem above, written by an aging Holocaust Survivor, reflects the multi-faceted nature of the role of coordinator of services for hospitalized Holocaust survivors at the Loewenstein Hospital Rehabilitation Center in Israel, and at other hospitals throughout the country. The coordinator provides survivors and their families with emotional counseling – Love – and assistance with entitlements – Food – while in the hospital, as well as a part of discharge planning. This role is unique to the Israeli health system and it was designed specifically to answer the particular needs of aging Holocaust survivors who are hospitalized in Israeli general hospitals and nursing homes.
The purpose of this article is to familiarize the professional community caring for Holocaust survivors with this special model, which can also be implemented in other countries, cities and communities with populations of aging Holocaust survivors.
I met my client, Miriam, for the last time when she came in with her husband, Jacob, for a routine checkup. She was more relaxed than I had remembered her. Apparently, she was managing well, now that her husband was back home with a 24-hour caregiver and she could look forward to getting back to her activities and hobbies. Most of all, she anticipated some immensely cherished quiet time for herself.
I was happy for her; she had been through some difficult times since her husband’s health had started deteriorating. He gradually lost his independence and relied more and more on her for his welfare and activities of daily living.
Jacob, 76 years old, was born in the town of Dorochoy, Romania in 1935. In 1941, when he was six years old, he was deported with his family to the area known as Transnistria (on the Moldovan border across the Dniester River, today a part of Ukraine), where Jews were concentrated and where over 90% of them perished as a result of executions, hard labor, hunger and diseases. His father died in a labor camp and his mother died from an illness a short time before he immigrated to Palestine with his older brother in 1948.
In what was formerly known as Palestine then, he met and married Miriam, a Holocaust survivor herself, and they had three children. Jacob worked for over 25 years as an administrator in a hospital. He retired 11 years ago, when he began doing volunteer work, reading history books and playing Bridge. He and Miriam currently live in their own apartment in Tel Aviv.
Three years ago, Jacob suffered a brain stroke, which left him with cognitive and speech impairments, at which point Miriam became his primary caregiver. He was admitted to The Loewenstein Hospital for neurological rehabilitation following a second stroke, which left him with right hemiplegia.
The hospital social worker on his floor identified him as a Holocaust survivor while doing the initial intake interview, and subsequently referred him to me – the Coordinator of Services for Holocaust Survivors – for further intervention.
As part of my role, I contact each and every admitted survivor and his or her family. After an initial intake, I devise a treatment plan with the patient or primary caregiver that consists usually of both instrumental and counseling interventions.
The role of Coordinator of Services for Holocaust Survivors in Israeli hospitals was initiated approximately eight years ago by the chief social worker at the Ministry of Health and the chief social worker of the largest HMO in Israel – Sherutey Briut Clalit1. At that time, the government realized that the number of first-generation Holocaust survivors was decreasing at an increased rate. Most of the adult survivors had reached their 80’s and it was estimated that by 2025 the last of them – child survivors – would be gone. It also became evident that because the survivors were aging, their need for assistance in activities of daily living were increasing, while many of them, mainly new immigrants from the former Soviet Union, who were not receiving any benefits at the time, had difficulties covering the increased expenses caused by their diminished health and functioning.
At the time, the Israeli economy was improving and the government could consider increasing public spending for the needs of the survivors. Also at that time, Israeli media raised the public’s awareness of the plight of some of the survivors and the government had to respond to the public outcry that followed. Television reporters visited destitute survivors, lonely, frail elderly who showed empty refrigerators and the national conscience was turned on…
Since then, new and improved benefits for survivors were reinstated, non-profit organizations were founded and new legislation was passed in the Israeli parliament. The role of the coordinator was part of this new approach to answering the needs of survivors.
The role of the coordinator was developed on the basis of extensive research regarding the late effects of the Holocaust on its survivors. The basic assumption was that not all Holocaust survivors are the same, even though they are all labeled as “Holocaust survivors” (Cohen et al., 2003). I am reminded of an 85 year-old Auschwitz survivor who became angry with me every time I made a general statement regarding Holocaust survivors. “We are not one!” she exclaimed. Many of them report a low rate of post-traumatic symptoms and it is possible that some of them continue repressing their feelings, regardless of the difficulties in inter-personal relationships, as well as behavior problems caused by post-traumatic symptoms. The survivors can be differentiated into more vulnerable and less vulnerable groups, but it is still essential to keep in mind that this population is now at a significant stage in their lives. Fifty years later, they are experiencing late effects of the post-Holocaust syndrome, as well as life stressors, such as loss, illnesses, retirement and empty nest syndrome, which can reactivate the events of the Holocaust (Cohen et al., 2003).
Kuch & Cox (1992) found that almost half of survivors meet the DSM-3-R criteria of PTSD. Among these, sleep disturbances with nightmares of Holocaust-related content were almost universal. Reminders of the Holocaust evoke intense distress and cause physiologic reactivity in most survivors. Other symptoms, such as intrusive recollections, avoidance of reminders, difficulty concentrating, diminished interest in daily affairs and irritability are present in the majority.
During the first few decades after World War II, the clinical course by which the acute and sub-acute post persecution reactions would last longer than a few years was not foreseen by clinicians (Dasberg, 2003).
However, recent research and reviews on post-traumatic reactions and PTSD at advanced age in Holocaust survivors show that, 50 years after traumatic exposure, the prevalence of PTSD is 39-65% (Dasberg, 2003).
Elderly Holocaust survivors react with PTSD symptoms as a response to cumulative lifetime stress and added recent stress. Added stress acts as a trigger for late aggravation and also for releasing late onset of PTSD and post traumatic reactions (Dasberg, 2003). These releasing factors can be divided into 4 categories:
- Personal factors, outside threats, health problems and development factors related to transition from the mid- life stage to the aging stage. Personal factors include retirement, relocating to a new apartment or old age home, hospitalization or institutionalization, loneliness, faltering social support, demoralization, decline in income, as well as emotional triggers, such as nostalgia, re-experiencing of longing for the pre-Holocaust home, grieving over old, and often at the same time, new personal losses.
- Outside threats include new threats of war, Nazi war crime trials etc. Prot (2009) found that even when survivors are exposed to other traumatic events over their lifespan, successive traumas resulted in reactivation of the Holocaust trauma, and each trauma was followed by dreams concerning the Holocaust, rather than the current traumatic event.
- Developmental factors related to late-onset at aging have to do with the psychological process of reintegrating traumatic memories and reintegrating the individual’s past life as a natural process of aging.
- Health factors include reactions to severe conditions, such as cancer, heart surgery, and cognitive changes. Additionally, the fear of becoming dependent on others in the wake of declining health is perceived as a major threat among aging Holocaust survivors (Dasberg, 2003).
The triggers mentioned above are recent events that induce feelings of helplessness and fear of being forced into a passive role, which undermines the Holocaust survivor’s defense mechanism of mastery. These triggers reactivate the “re-sensitization” of old traumas in the face of aging problems. The triggers bring up memories of the original traumatic events of exposure to death and revive the traumatic disruption that took place under the impact of the genocidal persecution as if it is actually returning in the present.
Aging Holocaust survivors tend to respond to deteriorating health with intense fear, helplessness and also re-experience the horrors of the past in their original intensity, or, perhaps for the first time in her/his life, with belated grief and mourning (Dasberg, 2003).
Most of the Holocaust survivors treated in the rehabilitation hospital nowadays are aging child survivors with their own special characteristics of childhood deprivation (Dasberg 2001). It is possible that during their adult lives, there was a split between the outer shell of psychosocial adaptation and the inner core of infantile child features (Dasberg, 2001).
In her research, Prot (2009) found gender differences in particular PTSD dimensions – men were at more risk for symptoms associated with re-experiencing trauma, while women were more prone to suffer from persistent avoidance or numbing of general responsiveness.
The role of “Coordinator of Services for Holocaust Survivors in Hospitalization”
Social workers from all Israeli hospitals and nursing homes were chosen, or rather, volunteered to participate in the special training program for Coordinator Services for Holocaust Survivors in Hospitalization. It is noteworthy to emphasize that some of the men and women who volunteered for this role were themselves second generation survivors. They did this, in many cases, out of a personal need to better understand their own survivor parents and grandparents, or out of a wish to compensate their families and survivors, in general, for the hardships they had endured– a motivation to make the world a better place (Kellerman, 2008).
In the training, we learned about the complicated benefits available to the survivors, depending on their place of birth, what they had undergone during the war, year of immigration to Israel and more. Needless to say, the benefits system is complicated and bureaucratic, and survivors have had to utilize the expensive services of lawyers to receive the benefits to which they were entitled. Another important part of this training was learning about the long-term effects of post-traumatization on aging survivors and, more specifically, about the emotional experience of ailing and incapacitated survivors while in acute rehabilitation and long-term hospitalization. In the years following the initial training, there have been annual meetings and conferences to update coordinators on the new laws and benefits that survivors are entitled to.
Assistance with accessing rights and benefits
Assistance is required due to frequent changes made by the government and non-profit organizations in order to keep up with the needs of survivors. Also, in recent years, the basic definition of who is considered to be a Holocaust survivor has been amended to include persons who were born in North African countries that were under Nazi occupation (Tunisia, Libya, Algeria and parts of Morocco). We assume that it is difficult for survivors to keep up with the changes and make sense of the overflow of information regarding benefits in the media.
This includes counseling for the aging survivor and his/her spouse, the latter who is usually also the primary caregiver. Sometimes it is also necessary to provide counseling to the children as well, being second-generation survivors.
Counseling to the multi-disciplinary staff
This includes counseling for the staff, especially to the physicians and nursing staff, as well as patient advocacy regarding possible reactions and behaviors that survivors might exhibit while in the hospital. The coordinator works in close contact with the departmental social worker around issues of patient and family coping and adjustment to the illness and disability, as well as maximizing the efficiency of discharge planning.
Planning and producing the Holocaust Memorial Day Ceremony in the hospital attended both by hospital staff and patients and their families.
Initiating in-service training to social work and multi-disciplinary staff regarding the referral of patients and families to the coordinator, changes in benefits and the emotional and behavioral aspects of survivors in hospitalization.
Coordinator’s Interventions with Jacob and Miriam
Because of Jacob’s mental state, the interventions were with his wife Miriam. When working with Miriam, it was essential to remember that she herself was a Holocaust survivor and be sensitive to her own trauma and post-traumatic reactions. She can now be considered as suffering from multi-trauma – both as a Holocaust survivor and the primary caregiver of her disabled husband.
The following are the interventions that were used:
- Counseling around couples’ issues, such as loss of intimacy and friendship, loss of support, loss of symmetry in the relationship, as well as the need to put spouse’s needs above her own.
- Counseling around discharge planning and the wife’s dilemma regarding nursing home placement versus returning home with a 24 hour live-in caregiver. This involves a basic issue that aging Holocaust survivors struggle with – a promise to each other, whether covert or open, that, come what may, they will not abandon each other in old age. In the context of discharge planning, if Miriam was to place her husband in a nursing home rather than take him home, this course would be considered abandonment, and the guilt she would feel would be overwhelming and difficult for her to contain.
- Support and counseling to the nursing staff around the patient’s anxieties regarding: daily routine and treatment, distrust of medical team.
- Counseling around the complicated relationship between Miriam and her three adult children, all second-generation Holocaust survivors. Second-generation survivors have been found to suffer from a wide spectrum of emotional disorders, which are related to the long-term effects of massive traumatization in the survivor parents. These effects are manifest in areas of disturbance within the family, including in specific distortions in the parent – child interaction (Davidson, 1980). Some of the children tend to be guilt ridden and overprotective, or distanced and alienated.
- Assisting Miriam in the complicated and tiresome process of accessing her husband’s benefits vis-à-vis different government agencies, such as the Ministry of Finance, which pays eligible Holocaust survivors a monthly health pension.
In my years of serving as the coordinator at the Loewenstein Hospital Rehabilitation Center, I have experienced some successes and some failures while trying to help this special population. Working at a rehabilitation hospital has been an advantage when it comes to inspiring hope in these patients. I have met true fighters and survivors, as well as depressed and disappointed ones, who by the time I met them, felt rejected, abandoned and cast away by Israeli society.
My hope is that through our brief encounter and my efforts, I was able to restore some of their trust and hope.
1The Head Social Worker of Sherutei Briut Clalit is Mrs. Hani Shalit, who has devoted much of her time and expertise to the welfare of Holocaust survivors in general, and especially to the development of the Coordinator Program. She received a special award for her efforts and achievements.
- Cohen E., Dekel R., Solomon Z. and Lavie T. 2003. “Stress and the Ability for IntimacyAmong Child Holocaust survivors”. Society and Welfare. 23(4):391-409.
- Davidson, S. 1980. “The Clinical Effects of Massive Psychic Trauma in Families of Holocaust survivors”. Journal of Marital and Family Therapy 6:11-21
- Dasberg, H. 2001. “Adult Child Survivor Syndrome: on Deprived Childhoods ofAging Holocaust survivors”. The Israel Journal of Psychiatry and Related Sciences. 38 (1) :13-26
- Dasberg, H. 2003. “Late Onset of Post – Traumatic Reactions in Holocaust survivors atAdvanced Age”.In: Breaking the Silence. Rossberg. H. and Lansen J. (Eds.), pp311-348.
- Kellerman, N. 2008. “Transmitted Holocaust Trauma: Curse or Legacy? The Aggravating and Mitigating Factors of Holocaust Transmission””. Israeli Journal of Psychiatry 45(4):263-271
- Kellerman, N. 2001. “Transmission of Holocaust Trauma – An Integrative View”. Psychiatry: Interpersonal and Biological Processes. 64:256-267
- Kuch, K.; AND Cox, B.J. 1992. “Symptoms of PTSD in 124 Survivors of the Holocaust”. American Journal of Psychiatry 149:337-340.
- Prot, K. 2009. “Late Effects of Trauma: PTSD in Holocaust survivors”. Journal of Loss and Trauma: International Perspectives on Stress & Coping. 15(1): 28-42.
- Wilhelmina 2004. Bon Appetit, Wilhelmina – a Culinary Biography. Tel Aviv, Tamuz Publishing Ltd.(Hebrew)