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Encounters with Chronic Psychiatric Holocaust Survivors: Trauma, Psychosis and Functionality

By Irit Felsen, Ph.D.

Part I

Abstract

This paper describes encounters with Jewish survivors of the Holocaust who were diagnosed with schizophrenia and spent decades in psychiatric institutions in Israel. The interviews with the patients took place in the context of the Testimony Project (Strous et al., 2005). The focus of this paper is on personal experiences during the interviews as an important aspect of the relational co-constructed encounters of the author with the chronically hospitalized Holocaust survivors. Notably, the patients interviewed were not experienced as disconnected, detached or disorganized as would have been expected according to the diagnoses they carried and their decades of psychiatric illness and institutionalization. The intersubjective qualities experienced in the encounters are discussed in relation to the differential diagnosis of schizophrenia and post-traumatic stress disorder (PTSD) with psychotic features.

The testimony of one of the patients is described, illustrating the critical role of social support and social context in the development or exacerbation of post-traumatic symptoms and psychological defeat. The testimony that will be presented highlights the importance of attending to loss of functionality as an important aspect in the maintenance and exacerbation of PTSD.

The encounters with chronically psychiatrically hospitalized Holocaust survivors suggest that PTSD with loss of functionality, rather than schizophrenia, was the main reason for their condition’s chronic trajectory. It is argued that loss of functionality might be preventable, even in the presence of psychotic symptoms, if treatment of victims of mass traumatization includes, in addition to appropriate trauma-focused psychotherapy, a wider range of interventions including occupational and rehabilitative services.[1]

Introduction

The patients whose testimonies were taken in this project were all Holocaust survivors who had been previously diagnosed as schizophrenic and were hospitalized for decades in psychiatric institutions in Israel (Strous et al., 2005). At the time of the encounters recounted here, many of the interviewees denied experiencing current positive psychotic symptoms, and most of them denied ever having experienced any hallucinations. None of the patients reported bizarre delusions or demonstrated grossly disorganized behavior or speech. It is conceivable that over the course of their chronic hospitalization patients might have “recovered” from some of the earlier psychotic symptoms from which they might have suffered in the past. Alternatively, a diagnosis of complex PTSD following exposure to multiple traumatic events, with severe functional impairment (Karam, Friedman, Hill, & Kessler, 2014), with or without psychotic symptoms, might have been more appropriate for their clinical presentation. However, most of the patients described here had developed their symptoms and received their psychiatric diagnoses many years before the introduction of Post-Traumatic Stress Disorder (PTSD) as a diagnostic category in DSM-III (1980).

The meaning attributed to observed symptoms determines the availability of appropriate treatment. When the observed symptoms’ relationship to trauma is not recognized, this failure might compromise the effectiveness of therapy in helping individuals recover from trauma’s devastating impact. The lack of adequate attention to patients’ trauma histories and the unavailability of trauma-focused treatment at earlier phases in their lives might be partly the reason for the chronic and severe course of these Holocaust survivors’ psychiatric illnesses.

The life trajectories described in this paper highlight important questions about trauma, psychosis, and functionality. Reflecting upon the differences between the elderly trauma survivors who were the chronic psychiatric patients and others who are symptomatic but nonetheless functional in the community raises questions about the meaning of recovery or functionality. Are these phenomena to be understood as an absence of symptoms or as a way of living more adaptively with the symptoms, whether these are positive or negative psychotic symptoms? Elaborating upon the interview testimony of one of the chronically hospitalized survivors will highlight the similarities between symptoms of severe numbing and avoidance and what might appear as negative psychotic symptoms.

The experiential, intersubjective qualities of the interviews, so different from what would have been expected in the encounter with chronic schizophrenic patients, highlight the need to further explore the differences between schizophrenia and trauma-induced PTSD with psychosis. It is suggested that PTSD, and not schizophrenia, could be the major debilitating illness that propelled some of the patients onto a chronic psychiatric trajectory.  Such an alternative clinical conceptualization underscores the critical role of psychosocial factors that promote and sustain the capacity observed in some survivors for a functional life residing in the community, alongside long-term effects of post-traumatic disorder, even including psychotic symptoms.

The Testimony Project

Twenty-four chronically hospitalized Holocaust survivors in two psychiatric hospitals in Israel were interviewed. The initial interest in these patients was instigated by some reports that appeared in the Israeli press during the 1990s (Bazak Commission, 1999) about a disproportionately large number of patients in psychiatric hospitals in Israel who were Holocaust survivors. Many had been hospitalized for decades. These patients’ trauma history had been neglected for decades and their needs as a unique group had not been addressed (Greenwald, Laub, Ben-Ari, & Strous, 2006; Strous et al., 2005). Though these survivors had been placed around the country in various psychiatric hospitals, these patients were finally identified as a distinct group and gathered to live in special settings built for them; it was in these settings that the Testimony Project took place.

Most of the patients, all of whom had been children during WWII, lost their families in the Holocaust. A handful had survived the Holocaust together with one or even both parents, with whom they had contact during their initial psychiatric hospitalizations. After their parents passed away, relationships with the outside world shriveled to nearly none for all of the interviewees, as relatives who kept in touch became fewer, and their visits less frequent. Many of the patients never married, and had no children. Even those patients who did have children did not have much of a connection with them after so many years of chronic hospitalization and absence from the family. These were, to a large extent, the most forgotten and the loneliest survivors of the Holocaust.

The purpose of the project was to document the testimonies of those for whom there would be no other witness. The catastrophic injuries and extreme plight of these Holocaust survivors have gone relatively unnoticed and undocumented within the larger body of survivor narratives. Chronic psychiatric patients comprise a particular, silent, and less well-known group along the spectrum of post-traumatic reactions, yet a group that might hold important clues as to the relationship between trauma and psychosis.

With one exception, there were no family members who could provide additional information about the history of the patients interviewed. Medical charts from the times of their initial psychiatric contacts were unavailable after so many years and so many different hospitalizations. Early reports, which might have been taken with greater attention than the terser and terser reports from later hospitalizations, were lost. The nature of the original signs and symptoms that repeatedly brought these individuals to psychiatric hospitals remained unknown to us. When asked directly, the survivors themselves often did not confirm, and sometimes even firmly denied, a history of positive psychotic symptoms such as hallucinations or delusions. Rather, like Shimon, who will be described in the following sections, they often described a vague and progressive loss of capacity to function in the world, an inability to hold down a job and hence to afford a home, and an increasing loss of motivation and hope, combined with a feeling of aloneness that became too much for them to cope with. In the absence of other options, psychiatric institutions became the only available solution.

It is conceivable that there had been positive symptoms that the interviewees did not remember or did not wish to report. The current assessment revealed an average Positive and Negative Syndrome Scale (PANNS) score of approximately 4, indicating an average moderate level of symptomatology that, according to the scale interpretation, “intrudes on daily life only moderately or infrequently.” The individuals we met had been diagnosed at some previous time as suffering from schizophrenia, but the appropriateness of that diagnosis seems debatable in retrospect. Most had been initially diagnosed many years before the introduction of PTSD into the psychiatric nosology in DSM-III (1980). Whatever their condition was, and whether it involved positive or negative psychotic symptoms or both, it appears to have been severe enough to have caused a retreat from life in the world. The individuals we interviewed had confined their survival to the psychiatric institutions that would house them. The conditions in these institutions were not good in the early years of the state of Israel. Limited resources and multiple pressing problems did not leave much for the care of chronic psychiatric patients (Davidovitch & Zalashik, 2007; Yablonka, 1994; Zalashik, 2008). The possible relationship between the symptoms of their mental illness and the patients’ traumatic history during the Holocaust was not typically explored at that time, and was often not recognized by the survivors themselves (Klein, Zellermayer, & Shanan, 1963). Psychiatric charts often read simply, “The patient immigrated to Israel from Poland in 1947,” without relating this to the context of the events endured during WWII and the Holocaust. Tragically, as has been pointed out by various commentators, including Dasberg (1992), Krell (1997), and Solomon (1995), psychiatry—not only in Israel, but as a profession—failed to address the Holocaust and its impact on survivors for several decades following the end of WWII. This denial by the mental-health professions constituted an additional trauma and exacerbated the re-entry of survivors into society (Dasberg, 1992).

Most of the patients interviewed reported that for some period after immigrating to Israel, they managed to function in society. Some, like other Israelis their age, were drafted into obligatory military service, and many were able to obtain jobs at which they worked for some years before they became dysfunctional. The patients reported having demonstrated a better adaptive capacity in the period immediately following their traumatic experiences, notwithstanding the added difficulties of immigration and acculturation in a new state limited in its resources and infrastructure of services. A few years later, however, it appears that these individuals experienced a loss in their capacity to navigate their way to resources and engage with the environment around them in ways that might have promoted health and better adaptation.

The role of both available and perceived psychosocial support has been especially highlighted in recent studies of delayed-onset PTSD (Norris, Tracy, & Galea, 2009; Smid, 2012). Studies of refugees from political conflicts have shown that the severity of relocation and acculturation to the new environment add significantly to their emotional burden (Bolton, 2015; Turner, 2004). Post-trauma stressors were found in some studies to have been more highly correlated with the onset of mental illness than the severity of exposure to trauma in the countries of origin before immigration (Knipscheer & Kleber, 2006). In combat veterans, a postponed onset of PTSD symptoms was observed in individuals who initially showed good adaptation following trauma exposure when perceived social support was low (Holowka, Marx, Kaloupek, & Keane, 2012; Marshall et al., 2006). Similarly, a prospective study examining factors associated with PTSD following the destruction of the World Trade Center in 2001 among adult residents of New York City also found that social support was one of the factors predictive of the development of late-onset PTSD (Adams & Boscarino, 2006).

Meta-analyses of studies of various populations exposed to mass trauma conclude that actual and perceived social support is the single primary factor determining outcome with regard to both ordinary and extraordinary stress (Norris, 2009; Norris  et al., 2009). It is especially important to understand the role of social-support factors in the capacity to sustain functionality, even in the presence of symptoms. As Rodriguez, Holowka, and Marx (2012) state: “Although symptomatology may be the substance of the disorder (PTSD), impairment defines its form. Ultimately, functional impairment may be the out­come we are most interested in ameliorating and thus, paying specific attention to its assessment is crucial” (p. 660).

Life trajectories of the patients interviewed in the Testimony Project, consistent with the research reviewed, suggest the importance of other factors, in addition to the presence of appropriate mental-health services, in helping survivors adjust to life after trauma. Equally important are a range of social-support services, including occupational and vocational opportunities, as well as opportunities for engaging and participating in interpersonal and community strength-building activities (Harvey, 2007; Tummala-Narra, 2007). Tragically, for many of the survivors we interviewed, these necessary conditions were not met. Faced with social defeat and isolation, they appear to have succumbed to chronic illness.

Personal Experiences in the Encounter with Chronically Hospitalized Holocaust Survivors

The encounter with the interviewees felt all the more overwhelmingly tragic because these chronic patients did not seem all that different from many other survivors who did manage to live their lives outside of mental institutions and have some measure of success in certain areas of adaptation — often despite the presence of some psychiatric symptoms.

Amnon Dankner’s 2008 novel “Aunt Eva, his days and his nights” captures the palpable, visible marks of recent suffering that many survivors still carried even as they moved forward in life after immigrating to Israel. In its recounting, the survivor, Aunt Eva, speaking of the people on the streets of Jerusalem in the 1950s, puts it as follows:

“When we walk tomorrow in the street, look at the faces of the people and you tell me if there is someone there who has no wound. You tell me who is not an orphan.” And, indeed, it was easy to see on the faces of the people in our town exactly what Aunt Eva said. The fear and the anguish, the terrible memories, the nightmares and the deprivation were still etched in them even as the times became better, little by little … The muscles of their faces were permanently strained in an expression of effort … They are straining to understand. To understand what happened to them and what is happening to them and what will happen to them. People are this way all over the world, but among us in particular (p. 87; my translation).

I was profoundly surprised by my encounter with the hospitalized Holocaust survivors — both by the sheer length of the interview sessions and by the sustained efforts that the chronic psychiatric patients made to talk and to communicate. I was also surprised by my own immediate intersubjective experiences with the people, my associations, and the quality of the feelings when being with them. The survivors did not feel unconnected or disorganized, as one might have expected from patients suffering from decades of chronic schizophrenia. Many did not seem all that different from other elderly survivors I have known personally and professionally, living their lives outside of mental institutions in TelAviv, Jerusalem, and New York. Some such survivors have never accessed mental-health services and suffer from various symptoms; some even manifest psychiatric disorders, including certain psychotic symptoms (Felsen, in preparation). Yet many of these individuals have, by external measures, led successful lives, achieving financial comfort and raising functional children. The lack of clear-cut differences between them and the chronically hospitalized patients highlighted the total devastation and defeat the latter experienced in their lives.

The stories of the lives that the chronically hospitalized survivors tried to lead after the end of the Holocaust revealed an absence or failure to maintain intimate relationships, careers, and relationships with their children. In the psychiatric hospitals where they lived, at times under deplorable conditions, these survivors were protected but were without personal freedom, were deprived of any comforts, and led an existence that seemed like enactments of Holocaust-era scenarios. The decades they spent in such institutions evinced profound invisible injuries, injuries which perhaps could not be told in any other way than as enactments, as a life lived in some form of continued hiding, dependent on an “other” for shelter and protection from a threatening outside world.

The testimonies given by the hospitalized patients were parsimonious yet fascinating. There were many gaps between words, entire sentences were missing as their narratives trailed off, and essential parts of their stories were left out and left unexplained. Yet the holes in the narrative seemed to be at its center, the most important and painful part, its perimeter sketched by those few things, less grave, that could be sparsely put into words. The absence was glaring; it was as if there was no need or possibility to articulate that which was not articulated. This in my experience is not an altogether unusual phenomenon in the testimonies of Holocaust survivors, even among some who are highly functioning and able to speak fluently and coherently about their traumatic experiences. The enormity of the most terrible and inconceivable moments is often left somehow unspoken in these sentences with missing pieces that avoid articulation of that which is almost said. Likewise, with the chronically hospitalized survivors, the absence of speech at these critical junctures was a felt presence, a palpable feeling of dread, similar to that which one would experience standing at the edge of an abyss but not falling in. The affective flatness that appeared at times when unimaginable atrocities were referred to, the speechlessness that seemed to fill particularly frightening moments of the story, manifested the limits of their capacity to represent such extreme experiences in symbolic language. Disbelief in their very capability to express—let alone make themselves understood—was evident in the obviously incomplete, faltering narrative, as well as in verbal and non-verbal gestures of despair they made while speaking.

In her 2015 essay for the New Yorker titled “The Memory Keeper,” Masha Gessen writes about the Nobel laureate Svetlana Alexievich, whose books represent a special genre of literature documenting interviews with survivors of traumatic historical events, including WWII, the Soviet war in Afghanistan, and the nuclear disaster at Chernobyl. Gessen states that Alexievich documented “oral history stripped down to segments so raw that it can stretch both credulity and the reader’s tolerance for pain” (p. 36). Similar experiences pervaded our encounter with the chronically hospitalized survivors in the Testimony Project. Alexievich described that in her interviews with survivors of traumatic experiences she came to realize that she could not use hand-written notes; she needed to document the person’s mode of speech, the way words were used, including the silences, in order to capture such experiences.

Sensitivity to the way the story of trauma is told as a measure of the level of integration of emotional and cognitive mental representations is also central in research from the attachment field. Studies utilizing the Adult Attachment Interview (AAI) assess the degree to which traumatic experiences in the adult’s attachment relationship have been integrated and resolved (or not), paying particular attention to the level of fluency and coherence in the manner in which the story of the trauma is told. The revolutionary contribution of the AAI was to shift attention from the description of childhood experiences to the current mental representations of these experiences and the recognition that the form of presentation of past experiences, rather than the content of memories, can be a direct measure of their traumatic impact (George, Kaplan, & Main, 1985; Hesse & Main, 2006; Van Ijzendoorn, 1995).

The phenomena seen in the discourse and verbal presentation of the testimonies of hospitalized survivors, most of whom were child survivors, is consistent with the cognitive approach that attends to the presentation of material at least as much as to the content of memories. In contrast to testimonies given by non-psychiatric Holocaust survivors, many of which can be viewed online,[2] the vacant gaps in the testimonies of the hospitalized patients seemed to have taken the foreground in relation to the entire narration. There were not just trailing sentences, or incomplete statements, but rather gaping holes in the narrative, accompanied by an obvious lack of the affect that would be expected at crucial traumatic moments, such as the death of a parent, or being separated from one’s sibling while escaping. The effect of this erasure of memories and emotional impoverishment was powerfully evident in the recounting of entire significant periods of life — even more so as it contrasted with the felt relational connection with the interviewers during the other parts in the conversation. In the most painful parts of the testimony, those pertaining both to the Holocaust and to later times when the devastation began to take over their lives, the narrative form and affect were so minimal that it was as if the survivors attached no importance to their losses, or to the absence of family, friendship, or romance in their lives. As a result, the very manner in which the stories were communicated told of a life as it were unlived.

Neuroaffective Understanding of Intersubjective Co-Constructed Experience

Over the course of recent decades, a paradigm shift has occurred from intrapsychic theory to relational intersubjectivity. Relational intersubjective theories posit that psychological development and the organization of the self, as life-long patterns of relating to self and other, emerge within and are continuously co-constructed by relational systems (Fosshage, 2011; Stern, 1988). Moreover, it has become accepted that much of the encounter between the subjectivities of self and other occurs on an implicit, pre-reflective, non-verbal level and leads to an intersubjective, direct, immediate, and emotional knowledge of the other’s inner experience (Ginot, 2015; Lyons-Ruth, 1999).

Findings from neuroscience research increasingly show that our brains are evolutionarily primed to receive and impart a great deal of nonverbal intersubjective information, particularly of an emotional and visceral nature (Cortina & Liotti, 2007, 2010; Schore, 2003, 2011). What we communicate, in life as well as in therapy (Miller, 2004, 2008), extends far beyond what we consciously intend to, and much of it is involuntary and outside of our awareness. The work of Schore and others (Kimora, Yohino, Takahashi, & Nomura, 2004; Sato & Aoki, 2006) has emphasized, in particular, the role of the right brain hemisphere in nonconscious communication processes. Damasio (1994/2005) and Adolphs, Damasio, Tranel, Cooper, and Damasio (2000) also conclude that the right hemisphere is the one involved in recognizing other people’s emotional expressions. Being extensively connected to the limbic system and sensitive to conscious and nonconscious interactional communication, the right brain seems acutely perceptive of emotional and viscerally felt experiences in others (Schore, 2005).

Another fascinating development in the understanding of how people “get” the emotional states, bodily sensations, and behavioral intentions of others comes from the scientific study of mirror-neuron systems, as well as from findings that demonstrate our ability to inhabit the emotional states of others. Consistent findings showing specific brain structures’ activation in response to observing others (Decety & Chaminade, 2003) have begun to delineate what occurs biologically when individuals, even strangers, are engaged with one another. These studies, using fMRI and other brain-imaging techniques, show that we have a biological propensity to replicate someone else’s neural activity in our own neural system (Gallese, 2006, 2008, 2009; Iacoboni, 2007, 2008; Iacoboni & Dapretto, 2006). This built-in neural-mirroring simulation seems to establish a direct experiential link and be at the basis of our capacity to understand the feelings of others. This capacity, in Gallese’s terms “the shared manifold of intersubjectivity,” is the neuropsychological process underpinning empathic responses, and is automatic, effortless, unintentional, and unconscious (Iacoboni, 2008). What is communicated is transmitted and received intersubjectively through facial expressions, gestures, gaze, vocal qualities, and bodily movements (Beebe & Lachmann, 2003; Bucci, 2011; Fonagy, Gergely, Jurist, & Target, 2002; Gallese, Eagle, & Migone, 2007; Lyons-Ruth, 2003; Schore, 2005, 2009).

The confluence of psychoanalytic thought and neuro-affective research has led to a growing recognition of intersubjectivity as an essential aspect of all human interactions and as a central mechanism in the psychotherapeutic process in recognizing the inner experience of the other (Ginot, 2015).

The Diagnostic Meaning of Intersubjective Deficiency in Schizophrenia

Intersubjective interpersonal communication occurring at nonverbal, nonconscious levels might be an especially important avenue for getting information about traumatic experiences (Stolorow, 2007). Limitations in the capacity to verbally express experiences of extreme traumatization have been described by many (LaMothe, 1999; Robjant & Fazel, 2010; Schauer, Neuner, & Elbert, 2011; J. Stern, 2000). The inadequacy of verbal, symbolic language to communicate the subjective experience of extreme trauma highlights the importance of other forms of communication of traumatic experiences. In the context of the Testimony Project, nonconscious intersubjective interpersonal communication was of particular relevance as it was experienced in the relational qualities of the encounter with the chronically hospitalized patients. While the patients had been diagnosed with chronic schizophrenia, they did not feel at all disconnected or detached. Yet these latter features have been historically viewed as critical elements in the pathology of the schizophrenic disorders. Parnas, Bovet, and Zahavi (2002) trace the historical origins of observations regarding the clinical phenomenology of schizophrenia, starting with Bleuler (1908), who defined an autistic detachment as the core pathology of schizophrenia and described the clinical manifestations of the schizophrenic disorders as including: poor ability to enter into contact with others, withdrawal and inaccessibility, rigid attitudes and behaviors, deranged hierarchy of values and goals, inappropriate behavior, idiosyncratic logic and a propensity towards delusional thinking. They also quote Minkowski’s (1933) argument that schizophrenia cannot be described by medical signs and symptoms unless the latter are informed by overarching considerations on the nature of subjectivity and experience. He posited that every psychiatric syndrome is characterized by a specific phenomenological core around which the symptoms are organized and from which they derive their meaning. Minkowski, too, considered autism to be the core of schizophrenia, defining it as a deficit in the basic, nonreflective attunement between the person and his world, a “lack of vital contact with reality, a lack in the ability to resonate with the world, to empathize with others” (p. 132).

Many of the classic psychopathologists took a similar position with regard to the diagnosis of schizophrenia. These earlier conceptualizations, in contrast to the operational criteria in the DSM and ICD symptom classifications, posited that diagnosis relies on a certain characteristic “gestalt,” irreducible to single symptoms and signs, which distinguishes the disorders of the schizophrenic spectrum from other disorders. Parnas, Bovet, and Zahavi (2002) review some of the terms used to denote these concepts of diagnosis, including: diagnosis by intuition (Wyrsch, 1946), atmospheric diagnosis (Tellenbach, 1968), Praecox Gefühl (Ruemke, 1942), and diagnostic par penetration (Minkowski,1933), all of which converge in indicating a deficient quality in the intersubjective nature of this gestalt and in using the feeling of the diagnostician about the quality of the encounter as diagnostic. From this perspective, the interviews with the patients in the Testimony Project provided intersubjectively co-constructed experiences between the interviewees and the interviewer which might have given the interviewer a glimpse into the inner experience of these trauma survivors. This type of communication might be especially valuable in providing some form of expressive sharing for those aspects of traumatic experiences for which verbal articulation was not possible. To demonstrate some of these processes in the intersubjective communication during the interviews, one testimony will be presented in greater detail.

Shimon

Shimon’s self-report regarding his childhood did not include evidence of developmental aberrations or social difficulties, such as are sometimes observed in the childhood and adolescence histories of schizophrenia patients. Shimon says he was the youngest in the family, and that everyone “watched over” him. He described himself as a well-functioning child, a good student who had a normal and engaged social life. He mentioned being a “soloist” when singing was organized, so he was not likely to have been too shy or withdrawn. He took part in group activities as a Zionist “pioneer” and developed a communist orientation, very different from that of his religious Chassidic parents. He communicated, in a matter-of-fact, non-self-serving style, that during the war and his various ordeals, he was a competent young kid: “I managed, everywhere I was.” He reported that he was physically strong, which is why he was able to appear older than his age and be sent to forced labor, instead of being selected for death. He managed to escape, somehow with his brother’s help, but it is not clear where exactly his brother was, since Shimon recounted being alone while hiding in the field of corn when a border policeman was trying to catch him and was shooting at him. It seems that he was likable and people were inclined to be friendly toward him: The peasants he worked for were not suspicious of him, the cook in the house to which he escaped fed him and saved his life, and the wife of the manager of the orphanage helped him find a better job than his old one of carrying buckets of water while barefoot. He even helped the younger children at the orphanage and shared food with them when they were hungry.

Shimon’s language was beautiful, more formal than colloquial spoken language, yet without sounding stiff. It certainly did not reveal any of the linguistic aberrations and violations that have been ascribed to schizophrenic speech formation (Hoffman, 1993). His speech combined words and concepts reflecting his background knowledge of Jewish tradition with high linguistic standards that characterized the “kibbutz” style of Hebrew of his time. That style emphasized the use of rich vocabulary and grammatically correct language, as opposed to more “sloppy” modern spoken Hebrew. Yet he used this more formal language in a natural and easy-flowing way, and it came across as rich and layered but not as pedantic or stilted. Shimon related that despite his previous high academic aptitude, after the war he was unable to study. In speaking about this painful topic, he used self-directed humor and an original and appropriate metaphor. He said, “Now Shimon [was] studying Torah shebe’al peh”(oral tradition, referring often to the Talmud)—to indicate that now he was only capable of the kind of learning which did not require the concentration that formal learning does. His memory for some of the historical facts of the time was good. In fact, he corrected Dori (an interviewer) on a couple of occasions and offered to show on a map of Europe the exact locations of the places he mentioned.

It is this very connected, reasonable, organized conversation that makes the way Shimon addresses the more traumatic material so jarring. It is as if, until that part of the interview, one has a sense of a good connection and rapport with Shimon: a sense of being alike, of mutual understanding, and the comfort arising from it. But all that is disrupted when in his testimony, he begins to address the deaths of his parents. In a matter-of-fact, flat manner he describes how his mother died in a hospital in a nearby town, and how he and his father had to turn back on their heels, unable to go see her because of a severe snowstorm. Then he describes how his father died on the bench next to him, and then how his sister died, all within three months. The terse description of these events, without any mention of how they were experienced emotionally at the time, or any trace of emotion in their present telling, leave a gaping hole in the stomach of the listener. At that point, one indeed feels cut off from Shimon. Unexpectedly and drastically, the sense of connection is severed, and he is experienced as deadened within.

Shimon himself addressed this feeling a couple of times, commenting that “We did not feel… We envied the dead…” What did you feel when your mother died? “We were not normal, to feel feelings… at all. No feelings, no attention paid …” No pain, but did you feel fear? “Fear there was from the goyim. Then they put me into the orphanage… I cut wood, carried water… One sister went to the synagogue [to sleep there with those who had no other place]. She died there… Every month, month after month [someone died]…” From what? “Dirt, hunger…” You were left with a brother and a sister? “No, we were not together; I was taken to forced labor… from the orphanage…” What did you feel when your father died? “I tell you, I did not feel… It was completely understood… We were not normal, not in normal conditions…”

Discussion

Bromberg (1998) proposed a nonlinear object-relations view of self-organization to describe the complicated relation between intersubjective knowledge and dissociated aspects of the self. Bromberg’s view maintains that the self structure is actually composed of internalized aspects of self and object possessing various degrees of consciousness or association with an aware “me.” The degree and nature of the dissociation from the conscious sense of self is largely determined by trauma, by perceived dangers to the self, and by the defenses set in motion to protect the sense of self from intolerable anxiety aroused by threatening or forbidden aspects of the self or the object. This model of mental structure provides a dynamic understanding of a complex, internal structure comprising multiple self-states, suggesting how they relate to one’s conscious sense of self and how they are played out in interpersonal communication and relationships.

In light of this view, the dramatically different ways in which I experienced Shimon intersubjectively during the interview might be consistent with the varying degrees of dissociation of his self-states. When talking about the most painful moments, the dissociation is much more severe than in previous parts of the conversation, dramatically and qualitatively changing the quality of the connection with him.

Sand (2010) seconds Bromberg in his conceptualization of the unconscious structure of the mind as multiple, shifting self-states. The essence of severe trauma, she argues, is the “disruption of the continuity of being”—that is, the disruption of the “illusion of being one self” (p. 363). In her view, dissociation is a defensive strategy against overwhelming experience, but it also constitutes a particular psychic structure. Dissociation describes a psycho-physiological process that prevents the laying down of verbal, symbolic memories in the first place. As a defensive strategy, dissociation banishes patterns of self-experience that cannot be tolerated as part of the “me.” It protects the stability of the self by controlling unsymbolized traumatic affect that it cannot regulate.

As a mental structure, dissociation develops over time when trauma and the need for dissociative defenses are severe, pervasive, and ongoing—and, perhaps most importantly, as Sand posits, when there is no alleviating responsiveness from the environment (p.364). A dissociative mental structure separates certain self-states and limits their communication with one another as a proactive defense against what has already happened. This conceptualization can aptly describe the erasure of important parts of experience observed in the testimony of Shimon and others among the chronically hospitalized survivors.

This concept of dissociation in the aftermath of trauma, especially trauma experienced by children and youth, is consistent with the bio-psychological diathesis model. Based on observations and studies with traumatized children and parents, and bridging the research fields of trauma and attachment theory, the diathesis model stresses the importance of at least three factors in determining the reaction to traumatic stress. These include: the severity of the trauma, the constitutional vulnerability of the stress-response system, and the capacity of the attachment system available to the individual to moderate and modulate traumatic stress (Lieberman, 2004). Each of these factors contributes to the outcome in terms of the level of adaptation or dissociation experienced following trauma exposure. Not all those exposed to potentially traumatic stress will develop post-traumatic reactions. The subsequent degree of pathology or adaptive functioning thus lies on a continuum between severe pathology and less severe post-traumatic reactions, including good adaptation after traumatic exposure.

In addition to the range of possible degrees of severity in the effects of traumatic experiences, research on trauma-exposed populations has also revealed the complex relationships between trauma exposure, post-traumatic reactions, and resilience. Pathology and adaptive capacities in the aftermath of trauma are braided together, so that resilience in any given individual is not a static trait that is either present or absent, but rather an amalgam of partially overlapping, partially independent processes (Brown, Kallivayalil, Mendelsohn, & Harvey, 2012; Southwick, 2014; Tummala-Narra, 2012; Tummala-Narra, Kallivayalil, Singer, & Andreini, 2012). An individual may be resilient in some aspects of life and not in others. “Those with psychopathology still possess attributes that support their wellness and good functioning and those who are more resilient may still have some symptoms of distress that undermine their relationships and increase their relationship conflict” (Lamoureux, Palmieri, Jackson, & Hobfoll, 2012, p. 11). An individual might also show different degrees of resilience at different times in life, as a result of changes in the level of current stressors and available support. Speaking specifically about Holocaust survivors, Valent (1998) has stated that each aspect of resilience has a corresponding potential hurt and wound, noting as well that the relationship between survivors’ inner, subjective pain and outward high-functioning actions remains one of the most ambiguous themes of discussion in the literature. Similarly, Shklarov (2012) has pointed to the “paradoxical coexistence of good adjustment and painful memories.”
Findings from the WHO (World Health Organization) survey of mental health based on more than 50,000 participants in 20 countries showed that among those suffering from PTSD in the past 12 months, a history of multiple trauma exceeding four traumatic events was associated with more complex PTSD, earlier onset, longer duration, greater co-morbidity with other psychiatric disorders, and greater impairment (Karam et al., 2014). Shimon endured a state of pervasive, severe, and ongoing multiple trauma. He described the ensuing defensive and dissociative mental structure in his own words when, speaking about his reactions to the terrible series of traumatic losses he suffered, he said: “We were not normal… to feel feelings…”

Bromberg (1998) states that when self-states are kept separate and inaccessible, reflective mentalization is not possible; hence, no new learning is possible. This state of dissociation seriously compromises one’s capacity for intersubjectivity, mentalization, and learning from experience. Under such conditions, intersubjectivity is limited because new relationship situations evoke automatic responses that might have been adaptive in particular settings in the past, but which are not necessarily appropriate in the new setting. In the absence of mentalization, rigid and automated traumatic learning governs the reactions to new situations in the present, such that all new relationships and situations are seen through the lenses of old traumatically-laid schemas. Clearly, this can severely compromise adaptive coping, especially in a complex situation requiring as much new learning and adaptation as that of a refugee in a new country and very different society, such as such as the one in which Shimon found himself when he came to Israel.

From Shimon’s account of his life, it appears that for as long as he was operating within a holding social environment that offered ready relationships and clear roles which relied on his strength and physical ability, he felt he belonged and was able to cope well. Once he left the kibbutz and found himself on his own, however, he was faced with city life which required autonomous and independent, self-directed functioning. At that point, Shimon’s difficulties in concentrating, coupled with his sense of loneliness, seem to have overwhelmed him. Shimon expressed in his own, very short and poignant words, that his entry into “the psychiatric process” was “unnecessary.” When asked if he thought it was because of the war, he replied quietly and immediately, “Sure,” adding: “It was because… there was no assistance.” And it was after that statement that he literally bolted out of the room, saying “Enough! Enough!”

As Shimon’s case illustrates, post-trauma psychosocial factors had been there for a while when he was living on the kibbutz, and seemed to have provided him with some scaffolding that supported better functionality. When he moved to the city, however, the psychosocial support provided by the structure, acceptance, and appreciation of his contribution to the kibbutz community were no longer there. Their absence constituted an additional stressor leading to the further deterioration of his previously better level of functionality. After he lost the capacity to make a living and hence remain independent, Shimon succumbed to life in psychiatric hospitals. And yet, from a clinical standpoint, this path might very well have been, as he put it, “unnecessary” had there been other supports available.

In addition to the severe, multiple, and prolonged traumata suffered during the years of the Second World War, once the war ended, the refugees had to cope with uprooting and resettlement in a country that at that time had minimal resources to help them (Yablonka, 1994, 1999). Some of the young survivors, like Shimon, also experienced acute exposure to re-traumatizing combat situations after they arrived in Israel and were drafted into the military. Due to their age, many of the young survivors who spent their adolescence in the war did not bring with them ready professional skills or education. Shimon’s ability to obtain further education was compromised by the loss of the ability to concentrate and study, as is typical in PTSD and depression. Shimon recounted that, after the war, his older brother put him in a WIZO facility, “where younger kids were placed,” because “I was not in… fit condition… I could not concentrate.” When we inquired, “Why? Before you had been a very good student,” his answer was simple and laconic: “The war… .” Shimon is now learning “torah shebe’al peh.” This answer, combining wry humor and an exquisite metaphor, is a poignant one, subtly hinting at his sense of the added loss of his previous intellectual potential. This added loss of the capacity to learn and to be considered bright and successful in ways that had been valued by Shimon’s early environment could have led to further loss of feelings of self-esteem and hope. However, while in the kibbutz, Shimon seems to have been able to counterbalance these potentially negative feelings with self-esteem built on his physical strengths; strengths which were valued in this environment as much as his learning ability was valued in his earlier environment. Having lost his previous capacity for formal learning, Shimon worked after the war doing physical labor in construction and agriculture. As long as he lived in the kibbutz, he seems to have functioned well, perhaps because physical work and strength were appreciated and held in high esteem in that social context, earning him a feeling of value and being included in the community.

It appears that in the kibbutz, Shimon found some sense of community and of togetherness: “We were united, morale was high, it held us…” he said of his experience there. Even while sitting in the bunker in Negba, during the invasion by the Egyptian tanks, he said he was not afraid: “It did not feel like there, in the Holocaust.” Asked if he could explain why, he replied, “Here we were at home; this was home.”

However, during the time he spent in the kibbutz, Shimon was not able to connect with a woman, which he explained by his own “lack of maturity.” He also mentions that there were very few girls in the environment he lived in, as life on a kibbutz at that time was very hard.

One is left wondering about Shimon’s history of repeated traumatic losses, including the death of his mother, the terrible snowstorm that made him and his father turn back, unable to go to her funeral, and its likely devastating effects on his father. This traumatic loss was followed by the death of his father from hunger one month later, which Shimon insinuated might have been his “fault,” as he was too tired to search for food. And one month later, his sister died. Did this horrific series of losses in early adolescence make it too painful to risk an intimate connection?

In the kibbutz and in the military, the sense of camaraderie of the group served an important relational and sustaining function. Unfortunately, even in this new “family,” someone close to him suffered a serious injury. Shimon says, about the commander of his unit, “I stopped the blood from gushing, with some old rags…” But he also adds: “It was supposed to be me in his place.” Those close to him almost all got hit, ending up severely injured or dead, he said. Is it possible that Shimon felt guilty about it?

I was struck by another, belated aspect of my reaction to this testimony. As I was preparing this paper to present at a professional conference, I was struck by the fact that the entire week, as I was struggling with this task, I found myself feeling irrationally guilty towards everybody — my husband, my daughters — for the time that I take away from them to do “my own thing.” While not totally a stranger to this particular guilty feeling, it had an unusually tight grip on me that week. Was it a fragment of a self-state that I absorbed from Shimon, as I was contemplating his testimony so intimately the entire week? I was conscious of feeling a paralyzing state of being stuck: unable to flow, to think, to create. Was this, too, a fragment of what Shimon communicated, which I was expressing experientially and enacting in my own life?

When his brother and his wife, like many others, left the kibbutz for the city, Shimon left with them, and there he became isolated and dysfunctional. In the city, he says he felt shut out by the “city folks,” and he explains it by him being different, a “kibbutznik.” Life in the city did not offer the same structure, support, and immediate feeling of belonging that life on a kibbutz did, organized as it was by work schedules, joint meals at the communal dining room, and many naturally occurring interactions while taking turns at various communal chores. Finding people to connect with, on his own, did not work out well in the city. Shimon worked, but did not really manage financially. His ambition to become a contractor was not attained. He left one job after another. He wanted to get married and have a family, but “there was no possibility.” He became depressed and lost hope. His brother could not support him financially, either, and so, for lack of any other alternative, he entered a psychiatric hospital. Perhaps Shimon could have had a different life, had he been offered a little more support for psychosocial and occupational rehabilitation outside a chronic mental institution.

Shimon described a distinct difference between his bright, eager-to-learn self before the war and his post-war self, the latter suffering from difficulties concentrating and an inability to function consistently at a job or establish relationships. These were all symptoms that could be associated with depression and defeat, but were all also typical of PTSD. As Shimon spoke of his feelings while in the kibbutz, and of his loneliness in the city, one felt connected with him to a degree which is qualitatively different than that typical for chronically hospitalized schizophrenia patients. Despite the undeniable catastrophic loss of capacity to function in the world, there was a powerful experience of sustained intersubjectivity in the interaction with Shimon: we were picking up on subtle cues in gesture, tone, and affect, and, together, filling in historical details to complete the picture. Shimon’s exquisite use of higher language, metaphor, and humor was the furthest possible from the bizarre or disorganized speech that would be anticipated in chronic schizophrenia. Overall, there was a feeling of normalcy and mutually sustained interest, a shared mutual understanding and shared enjoyment in the interaction that was communicated in both verbal and non-verbal exchanges. The same was true with many of the other participants, despite their long decades of institutionalization.

With a little more “mazal”—a little more luck—things might have turned out differently, as they did with some other survivors. For example, Henry was fifteen years old at the end of the war. He survived the concentration camp with his brother, and when he arrived in the USA he was trained in a trade. Henry met another survivor and the two married very young after a brief acquaintance. Henry worked in the back room of a small shop, while his brother and his wife dealt with the customers and ran the business. Soon after he got married, Henry manifested severe depressive symptoms, and what would probably be diagnosed today as avoidance and numbing symptoms associated with post traumatic stress disorder. He was very quiet and detached at home, and rarely interacted with the family.  Occasionally, Henry’s symptoms would get so severe that he required psychiatric hospitalization. However, because Henry’s wife was a competent parent and a competent business woman, Henry had a financial and relational basis to return to after each hospitalization. The family business also provided a sheltered environment that allowed Henry to operate at the level he was able to sustain when not incapacitated by his psychiatric symptoms.

Kurt’s story was very similar. He also married another survivor shortly after liberation, and together they immigrated to the USA where they ran a grocery store. Kurt often exhibited rageful explosive outbursts, and also suffered from depression very soon after he got married. He, too, required multiple psychiatric hospitalizations throughout his life, during which his wife carried the burden of operating the store by herself and managing the family and the three children. When their symptoms were debilitating for periods of time, Henry and Kurt had wives who maintained each family’s source of income when their husbands were incapacitated. Due to their functioning wives, neither Henry nor Kurt experienced the down-spiral that could have ensued had they remained single before the onset or the exacerbation of their psychiatric symptoms. Both men had married shortly before their symptoms exacerbated, during a period when they reportedly were functioning better, similar perhaps to the period described by Shimon, when he, too, was functioning relatively better. Despite the onset of psychiatric disorders and the difficulties that were experienced by their wives in the relationships with these spouses, the marriages survived. Both Henry and Kurt managed to have established families and children, who were a source of positive experiences and support in their lives. Having that support provided a different environment to which the men returned after each psychiatric breakdown.

Shimon, in contrast, did not have the good fortune of having married and having established a family before his symptoms began to interfere with his capacity to maintain employment, and with the loss of this capacity, his ability to sustain himself without adequate social, occupational and rehabilitative supports was overtaxed. Shimon, who might have been no more psychiatrically ill than Henry or Kurt, did not have the social, financial and relational support to sustain him. Indeed, studies show that the availability of actual and perceived social resources and feelings of social embeddedness are critical factors in the late onset or exacerbation of post traumatic symptoms and in recovery (Dirkzwager, Bramsen, & Ploeg, 2003; G. E. Smid, van der Velden, Gersons, & Kleber, 2012).

The overriding feeling in the interview with Shimon was that this was a man who was completely and soberly aware of the tragedy of his situation, including the fact that it could have been avoided. He communicated this in a muted, dignified, and contained manner. But he did, however, come across as defeated. Whether or not psychotic symptoms were part of the clinical picture that Shimon experienced in the past may not be essential for differential diagnosis with regard to the trauma-related disorder from which he suffered. Kohler (2011) states that “the neuroscience of the severe mental disorders overlaps with the neuroscience of chronic and profound stress, trauma, social isolation, extreme loneliness and social defeat.” After Holowka, Marx, Kaloupek, and Keane (2012) examined the symptom distribution and stability over time in a sample of Vietnam War veterans, they stated that an unexpected finding was the “striking similarity in PTSD symptom severity and distribution between those with PTSD only, and those with a psychotic disorder only. Both groups showed similar patterns of symptom distribution and endorsed similar numbers of symptoms in each cluster, though individuals with psychosis only did not endorse the prescribed number of symptoms in each cluster to achieve the diagnosis” (p. 291). The authors also noted that more veterans with PTSD endorsed a restricted range of affect than veterans with psychotic disorders, which may speak to the importance of numbing in PTSD, suggesting that “numbing may be as much a hallmark of the disorder as intrusions” (p. 291). The symptoms that Shimon recounted are consistent with numbing and avoidance. If, as he stated, he indeed never experienced positive psychotic symptoms, then the avoidance and numbing symptoms he manifested have been sufficiently impairing to confine Shimon to lifelong hospitalization as a psychiatric patient.

Recent research highlights the importance of social support in the aftermath of traumatic exposure. A document published by the U.S. Substance Abuse and Mental Health Services Administration (2014), delineating guidelines for a trauma-informed approach, states: “The manner in which individuals and families can mobilize the resources and support of their communities and the degree to which the community has the capacity, knowledge, and skills to understand and respond to the adverse effects of trauma has significant implications for the well-being of the people in their community” (p. 17). The concept of resilience has evolved from the search for personal individual traits that allow some to overcome traumatic experience and even come out strengthened, through the examination of coping styles and mechanisms, to a current ecological concept of resilience as transactional, with multiple influences ranging from interactions between the individual and their family to the socio-cultural environment (Harvey, 2007; Tummala-Narra, 2007). In this model, there is a critical role for both intra-individual and interpersonal community resources which can act as “protective factors.” The unfortunate history of denial of the impact of trauma by the mental-health profession in the early years after the end of WWII (Krell, 1997; Solomon, 1995) has led to a delay in attending to the needs of the most vulnerable Holocaust survivors, and the lessons learned have come at a great cost for many individuals and families.

The current understanding of the transactional nature of resilience emphasizes the responsibility of professional advocacy in informing and influencing policy makers by educating them about the clinical and empirical phenomena observed by those who work with the survivors of trauma. The testimony given by Shimon illustrates the potential benefit that could be achieved by planning and providing opportunities for trauma-survivor refugees to connect with support groups, affiliative networks, and rehabilitative services. As Knipschpeer and Kleber (2006) state, creating opportunities for feelings of mutual connectedness and mutual responsibility might be a valuable path in enhancing resiliencies.

The testimonies of Holocaust survivors who became chronically hospitalized patients must be part of the documented narratives of the post-traumatic reactions that followed the Holocaust. The various ways in which individuals were able to recover, as well as the psychological defeat and chronic mental illness suffered by those who were not able to return to life in society, must be examined to allow better understanding of the role of community and social context. The life trajectories in the Testimony Project highlight the need for developing a wide range of appropriate mental-health and auxiliary social services to help survivors of trauma sustain functionality after extreme traumatic experiences.

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[1] A presentation based on the testimony described in this paper was given at the 11th annual meeting of the International Society for the Psychological Treatments of the Schizophrenias and other Psychoses at the Austin Riggs Center on Sunday, November 7, 2010.

[2] See the website of the United States Holocaust Memorial Museum: http://www.ushmm.org/remember/the-holocaust-survivors-and-victims-resource-center/survivors-and-victims/survivor-testimonies.

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