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EmailHolocaust Survivors, Coping and Well-Being
| Dr. Esther R. Greenglass, Phd. Department of Psychology, York University Toronto, Ontario |
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Survivors of the Holocaust have endured traumatic life situations and losses that defy comprehension. The literature on Holocaust survivors has been mainly about people who had been unable to cope. Little was known about those who managed to salvage their lives or how they coped with the challenges of their lives at the time. Most of those who eluded genocide in WW II were between 15 and 35 in 1945. Fifty-six years later they are in their late sixties and older. Awareness of the impact of war on older people is a relatively recent phenomenon. Holocaust survivors in the postwar years faced a triple challenge: First, they had to come to terms with, and cope with their own traumatic experiences; second, they had to cope with the losses of family members and friends, and third, they were challenged to take on the demands associated with relocation to new environments. After an initial period of adjustment, the majority of survivors took on the demands, challenges and opportunities afforded them by their new environments and used effective coping strategies in their adjustment to conventional aspects of postwar living conditions (Harel, 1995). For many survivors, their families are smaller than average since they lost many of their kin in the war. Many compensate for their losses by directing their emotional energy onto their children.
The work of April Shour, examining Toronto Baycrest's survivor population and published in the Journal of Aging and Judaism in 1990, was the first North American study on aging survivors in institutions. Robinson et al. (1990) report interviews with 86 survivors (average age 68.3) from a non-clinical population to examine coping and adjustment in elderly survivors. Their results showed that most of them suffered after the war and were still suffering from the effects of persecution. Despite their mental suffering, they managed to cope and to adjust. They were successful in work and society and they managed to raise warm families. While there is considerable evidence to indicate that some survivors have been scarred by their experiences, there is also a great deal of research evidence indicating that a large portion of them not only adjusted well as individuals but also made substantial contributions to collective communal efforts in their new environment. To date there has been only limited scientific effort directed towards the assessment of strategies used by survivors in coping with the long-range effects of the Holocaust and factors that aided their adjustment. There is also little information on proactive adaptations and coping efforts that survivors made to foster the process of recovery (Kahana & Kahana, 1996).
Trauma and Psychological Functioning
Research indicates that when stressors are severe, behavioral, social and psychological functioning may be affected. However, reactions to traumatic and extreme stress vary. Post extreme stress adaptation and experiences, along with environmental social resources, play a critical role in ameliorating extreme stress and enhancing well-being. There is also evidence that, while extreme stress may have intense negative effects, it may also generate some positive influence on the processes of continuity and change in the course of aging particularly (Harel et al., 1984; Elder and Clip, 1988). Unless researchers try to measure such positive experiences, their occurrence is missed. Such findings join a diffuse but growing literature in several areas suggesting that traumatic events can and often yield positive outcomes, including growth experiences (Affleck &Tenne, 1996; Aldwin, Sutton, & Lachman, 1996). The events studied have varied widely including bereavement, infertility, childhood sexual abuse, mass killings and plane crashes. There is some evidence that finding benefit in trauma may reduce later stress (McMillen et al., 1997); it seems to permit resolution of the experience, allowing the person to move forward with life (Carver and Scheier, 1998; Folkman, 1997). This research mirrors earlier writing by Viktor Frankl (1961) on survivors who find meaning in their experiences in the Holocaust. For Frankl (1961), suffering can lead to growth and emotional maturity. He argues that it is only someone who has suffered so much who can appreciate the educative character or growth potentials which can be realized when suffering is confronted in the right frame of mind.
In recent research, a scale was developed and tested among women with breast cancer who indicated the extent to which having cancer resulted in various positive experiences for them (Antoni et al., 2001). The scale consists of 17 items and assesses things such as, being more accepting, teaching people how to be more aware of others, as well as the development of several socially desirable traits such as becoming stronger, more sensitive and more loving. In this research, a stress management intervention increased women's reports that having breast cancer had made positive contributions to their lives. An implication of these results is the importance of collecting information on positive experiences as well as negative ones when studying people who are dealing with adversity.
Aging and its Effects
Given that most survivors are in their late sixties and older, they are increasingly experiencing the stressors associated with the process of aging. Research on the elderly suggests that aging is taxing and that with age many resources that individuals have taken for granted begin to dwindle. An essential aspect of aging is successful coping. This entails learning how to deal effectively with losses, disappointments, and decline. As they age, people have to cope with regular and frequent failure in attaining the action goals they set for themselves. With aging, people experience an increase in stressful life changes such as loss of a spouse, retirement, or forced relocation (Kahana et al., 1995; Bisconti and Bergeman, 1999). Additional stressors in the elderly include: bereavement, reduced income, illness, loss of a driver's license, and/or becoming a caregiver for a family member who is ill (Schultz & Heckhausen, 1996). For many elderly, stressors steadily accumulate, resulting in significant frustration in their aspirations to maintain a normative adult lifestyle and an increase in dependence on others. They may also not be able to engage in desired activities to obtain gratification in social relationships, resulting in further dissatisfaction. With aging, functional ability decreases. Many people find they are not able to do daily things that they used to take for granted. This may include bathing oneself, going up a flight of stairs or taking a bus or train oneself. In addition, certain chronic conditions become more prevalent with age such as arthritis, stomach problems, vision and hearing problems. With declining physical ability, there is a greater chance of accidents. The process of aging for the Holocaust survivor may be even more difficult and challenging since they may be experiencing yet again many of the losses they had in their youth.
Coping, Physical Rehabilitation and the Elderly
Several factors are related to coping successfully with stressors associated with aging, including one's declining functional ability. According to research, individuals must develop resilience to effectively cope (Schultz & Heckhausen , 1996). Most existing theories of successful aging focus on the ability to compensate for failure and decline. Others argue that a central feature of successful coping is the construct of control, with the assumption that humans desire the ability to exert primary control over the environment, including the changes that are occurring (Bisconti and Bergeman, 1999). Successful aging includes the development and maintenance of primary control throughout the life course (Schulz & Heckhausen, 1996). Significant associations have been reported between perceived locus of control and measures of functional or physical health (Baltes & Baltes, 1990). Those who have resources, including social support, due to their own efforts and their place in society, are better able to plan for future contingencies, and place themselves in positions that allow for risk minimization and resource maximization. Baltes & Baltes, (1980, 1990) argue that there are systematic age-related differences in both the availability of resources and in the efficient use of resources across the life span, with older people having access to fewer resources and being less efficient in using them.
Given their greater physical vulnerability with age along with a decrease in functional ability, the elderly often are referred to physical rehabilitation where coming for treatment, following through with exercise and persisting in the face of discomfort, are activities necessary to achieve progress. During rehabilitation, people sometimes talk about "getting on with their lives". This is to be contrasted with the view of the goal of physical rehabilitation as "recovery", which may be inappropriate. Rather than asking patients to focus on returning to pre-injured conditions, in shaping outcomes, the focus is often on the possibility of developing new and adaptive patterns of goal behavior. While "getting on with one's life" may mean different things to different people, in general it refers to the pursuit of behaviors and social relationships that give them day-to -day pleasure, feelings of well-being and being spiritually uplifted, and even joy. By conceptualizing the future in this way, patients are encouraged to focus on their values and interests and the behaviors they see as necessary to acquire in order to achieve their goals. Individuals may vary in the degree to which they want to get on with their lives, the degree of difficulty they anticipate in doing so, and the probability they perceive that they will in fact do so.
This situation of the elderly patient in physical rehabilitation can be seen as similar to that depicted by Brandstadter & Wentura (1995) when they describe the plight of the elderly in coping with developmental changes in general. As people age, in order to maintain particular standards, they employ a variety of strategies. They may try to boost their performance by increased training, concentrating on particular tasks, or use of external aids to compensate for functional losses (Baltes & Baltes,1980, 1990). To achieve congruence between actual and desired courses of development, individuals must either try to modify the course of personal development in accordance with personal goals and aspirations (assimilative mode) or adjust personal goals to constraints of development (accommodative model).
The behavior that occurs in the assimilative mode, as described by Brandstadter & Wentura (1995), can also be described as proactive coping and parallels Greenglass et al. (1999a & 1999b) when they talk about proactive coping as setting goals and having efficacious beliefs concerning the acquisition of these goals. Proactive coping integrates processes of personal quality of life management with those of self-regulatory goal attainment. Proactive coping differs from traditional conceptions of coping in three main ways: First, traditional coping forms tend to be reactive coping in that they tend to deal with stressful events that have already occurred, with the aim of compensating for loss or harm in the past; proactive coping is more future-oriented. Since the stressful events have already taken place, reactive coping efforts are directed toward either compensating for a loss or alleviating harm. In general, this is the type of coping that has been assessed in much of the research on coping to date. In contrast, proactive coping is oriented more towards the future. It consists of efforts to build up general resources that facilitate promotion of challenging goals and personal growth.
The second distinction between reactive coping and proactive coping is that reactive coping has been regarded as risk management and proactive coping is goal management. In proactive coping, people have a vision. They see risks, demands, and opportunities in the future, but they do not appraise these as threats, harm, or loss. Rather, they perceive difficult situations as challenges. Individuals not only do not necessarily wait for stress to occur, but actively set about positioning themselves and their resources in an advantageous position. The ideas put forth by Greenglass et al. (1999a & 1999b) and Aspinwall & Taylor (1997) are consistent with the COR (Conservation of Resources) thesis that people are active participants in looking forward in their lives, considering their goals, evaluating obstacles and advantages offered by the environment and acting to enhance their resources, including social support, and limit their resource losses (Hobfoll, 1989). In general, research indicates that external resources such as social support from others have a positive effect on the elderly's functioning and psychological well-being (Harel ,1988). There is also evidence that greater social support is associated with better mental health among survivors of extreme stress (Wilson et al., 1988).
Physical Rehabilitation and the Elderly Survivor
Contrary to earlier assumptions, research comparing survivors and immigrants has found that survivors had more stable families (lower divorce rates) and had somewhat more extensive social networks and higher levels of social interaction (Kahana et al., 1988; Harel et al., 1993). Survivors, compared to other immigrant group members, have also been reported to be more likely to give and receive assistance with shopping, repairs, cooking, and finances and were more likely to offer assistance in times of illness (Harel et al., 1993). Taken together, these results suggest that, in terms of social networks, social interaction and social support, aging survivors are doing as well and in some instances, better than members of appropriate comparison groups.
For survivors, coming to an institution to receive treatment, may be experienced as traumatic. It has been documented that medical symptoms are threatening to survivors because concentration camp inmates who became ill were often put to death (Helmreich, 1992). In addition, mistrust of the medical establishment and medical regimes have been found to characterize survivors (Krystal, 1968). This may result in their being exposed to potential triggers which might elicit difficult memories of the Holocaust. There are many possible triggers within the clinical area that could cause past memories to resurface. Technological procedures, especially those that may contribute to a sense of confinement, discomfort or loss of control, such as having blood taken, use of an electrocardiograph, or using a mechanical lift, can trigger unpleasant memories. Being assigned a number, being placed in locked areas, being required to take a shower or a bath, having their clothes taken away, shots or needles, being exposed to medical procedures and/or physical therapy are all potential triggers. Other potential triggers include lab coats, strict routines and schedules, having to stand in lines, and antiseptic smells (David & Goldhar, 1999; Bernick & Rodgers, 2001). For these reasons, physical rehabilitation may be a difficult and aversive experience for survivors.
The prognosis of the elderly survivor having physical rehabilitation treatment depends as well on their coping and social support resources. And, individuals vary considerably in the resources they bring to stressful situations, including physical rehabilitation. Better individual resources empower individuals to cope more effectively. Previous research suggests that survivors are just as likely as a control group to engage in instrumental coping strategies generally suited to general problems in living. Indeed, research suggests that self-perceptions of survivors often emphasize this propensity toward instrumental mastery (Harel, Kahana, & Kahana, 1988). To the extent that elderly survivors possess and employ coping techniques consistent with a proactive approach to life, it is expected that they would progress well in their therapy, despite any unpleasant associations the situation may evoke. And, research indicates that proactive coping is consistent with other coping forms that measure activity and initiation in coping, and is inconsistent with those assessing passivity and self-blame (Greenglass et al., 1999a).
Conclusions
While physical rehabilitation presents a challenge to the elderly, for the elderly survivor, it may be a particularly difficult experience. On the one hand, there is reason to believe that the rehabilitation setting itself may consist of possible triggers within the clinical area that could cause past memories of their horrific experiences to resurface. At the same time, available data suggest that survivors' self-perceptions are congruent with an instrumental and a proactive approach to stressors in general and to physical rehabilitation in particular. Through further research, some of these issues may be pursued in order to shed light on the process of growth and development in the aging Holocaust survivor.
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