P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

Style file version June 4th, 2002

C 2002)
Journal of Clinical Geropsychology, Vol. 8, No. 3, July 2002 (

The Phenomenology of Posttraumatic Distress in Older

Adult Holocaust Survivors
Danny Brom,1,2 Nathan Durst,1 and Gafnit Aghassy2

This paper focuses on the effects of the Holocaust on its survivors more than 55 years after
the end of World War II. The emphasis is on survivors who were either adults during the
Holocaust and who are now over the age of 70, or survivors who were children during
the Holocaust and whose age is now between 56 and 70. The central question was: What
kinds of posttraumatic phenomena are seen in older adult survivors? After an overview of
the field, the situation of survivors in Israel is presented in 2 ways. Results of a survey of
survivors who were referred to Amcha, the National Israeli Center for Psychosocial Support
of Survivors of the Holocaust, is provided to give some insight in a clinical population. In
addition, 2 case histories of survivors are presented to give a more in-depth perspective.
The gap between the data from the questionnaires and the clinical material has relevance
for the way in which we conceptualize the late consequences of massive trauma.
KEY WORDS: Holocaust; survivors; posttraumatic phenomena; World War II.

INTRODUCTION
Survivors of the Holocaust are one of the most well-known severely traumatized groups
that have reached old age. The horrors of the Holocaust have become a symbol of the evil of
which mankind is capable. From a historical and philosophical perspective, the Holocaust
has been the subject of much research and writing. However, those who have suffered
directly from the Holocaust have been studied much less extensively. Even more surprising
is the fact that psychosocial services for Holocaust survivors have been established, for the
most part, only in the past 1015 years. The suffering of Holocaust survivors was recognized
previously, but a treatment responsive to this suffering was developed only when many of
the survivors had reached an advanced age.
A short review of the research literature, showing that scientists have clarified the understanding of the psychological consequences of the Holocaust by adopting the symptoms
of posttraumatic stress disorder (PTSD) as the most relevant subject of study, is presented.
Next, data on a group of help-seeking survivors, collected at Amcha, a service organization
1 Amcha,

The National Israeli Center for Psychosocial Support of Survivors of the Holocaust and the Second
Generation, P.O. Box 2930, Jerusalem 91029, Israel; e-mail: dbrom@netvision.net.il.
2 The Israel Center for the Treatment of Psychotrauma, Herzog Hospital, Jerusalem, Israel.
189
C 2002 Plenum Publishing Corporation
1079-9362/02/0700-0189/0

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

Style file version June 4th, 2002

190

Brom, Durst, and Aghassy

for survivors of the Holocaust, are reported. To deepen the understanding of the lives of
survivors, two case descriptions are also presented and discussed.
Research on Holocaust Survivors
The long-term effects of the Holocaust on individuals can only be properly understood
when we know what people actually went through. The range of horrors that survivors
encountered during the war will not be elaborated on here. It is clear that the variation
of experiences among survivors is enormous, ranging from incarceration in extermination
camps with their unimaginable conditions, through years of fight and flight, to eluding
capture by the Nazis by hiding in private homes, in convents, or in the woods with the
continuous threat of being discovered. Most survivors went through several of these experiences. When taking into account the age at which the survivors underwent the horrifying
experiences, the country of origin, the socioeconomic and cultural background of each, one
can conclude that the Holocaust survivors are a very heterogeneous group. What they all
have in common, however, is the fact that all of them had many traumatic experiences,
innumerable losses, and, generally, did not have the opportunity to grieve. In addition, to
understand the effects of the Holocaust, one must take into account that during the years
before World War II, the situation of European Jewry deteriorated and the Nazi net pulled
closer. Most survivors were aware of this either through their own experience or by observing their parents. Equally important was the postwar situation, which often entailed years
of wandering through camps for displaced persons, looking for surviving relatives, coping
with new realities, and finally settling down somewhere and building a new life. The fact
that research on the consequences of the Holocaust has remained a relatively neglected
area in the field of traumatic stress might have to do with the complex nature of this massively traumatic sequence of experiences. The confrontation with such massive trauma has
deterred both clinicians and researchers from working with Holocaust survivors for many
years (Danieli, 1981).
Before official recognition of the diagnostic category of PTSD in the Diagnostic and
Statistical Manual of Mental Disorders, 3rd edn. (DSM-III; American Psychiatric Association, 1980), different authors had tried to define the syndrome they observed in Holocaust
survivors. Apparently, because of the shock of the revelation of the horrors of the concentration camps, early reports on Holocaust survivors only dealt with the psychological effects in
survivors of the camps; only later were those who had been on the run and in hiding studied.
The concentration camp syndrome was first described by Herman and Thygesen (1954);
other writers developed similar constructs such as KZ syndrome (Bastiaans, 1974) or survivor syndrome (Niederland, 1971). The early descriptions of the symptoms observed in
survivors included anxiety, sleep disturbances, impairments of cognition and memory (i.e.,
amnesia), nightmares, intrusive reexperiencing, numbness, chronic depression, psychosomatic symptoms (i.e., pain resulting from increased muscle tension and nervousness), and
personality changes (i.e., impoverished object relationships, general rigidity, and emotional
withdrawal).
Different researchers have studied the above symptoms since as early as 1952 and have
written extensive reports on their findings. The early literature is characterized by enumeration of a broad range of symptoms and by a strongly psychoanalytic conceptualization of
clinical observations. In the later literature, the studies became more focused, and many

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

Older Adult Holocaust Survivors

Style file version June 4th, 2002

191

different studies showed that survivors suffered from an increase in distress-related symptoms and decrease in life satisfaction in the decades after the war (Antonovsky et al., 1971;
Carmil and Carel, 1986; Cohen et al., 2001; Eaton et al., 1982). After 1980, many studies
placed a strong emphasis on the criteria of PTSD. A Canadian survey (Kuch and Cox,
1992) studied psychiatric examinations that were written up for the German Compensation
Boards. They scored the prevalence of the symptoms of PTSD in these files. Interestingly
enough, a scoring procedure was chosen which disregarded exposure to abuse, characterological sensitization, and chronic nonphasic depression, even though the guidelines of the
West German Compensation Law specified that these variables should be examined. The
authors only reported on the prevalence of symptoms of PTSD.
Another study examined the symptoms of PTSD and the presence of other major mental
disorders in 100 survivors, of whom 70 had survived the camps and 30 had survived by
hiding (Yehuda et al., 1997). This study, similar to the study of Eaton et al. (1982), found no
difference in symptomatology between the survivors who had been in concentration camps
and those who had survived in hiding. However, there was no assessment in the study of
broader life changes in the survivors.
Dissociative symptoms have been found to be present in Holocaust survivors, particularly among those suffering from PTSD (Yehuda et al., 1996), but not to the same degree
as in survivors of other traumatic circumstances. Similarly, psychogenic amnesia can be
found among Holocaust survivors (Van der Hart and Brom, 2000), but is less prominent
than that in survivors of childhood abuse.
The aim of this study was to assess symptomatology and posttraumatic phenomena
of first-generation and child survivors of the Holocaust. The survey was conducted in the
framework of Amcha, and its objective was to obtain more information about the survivors
who applied to Amcha, such as their motivations for applying, their present predicament,
and their coping styles in comparison with other groups. Amcha is a nonprofit organization
founded in 1987, which was developed as a low-threshold service for Holocaust survivors
and their families, with the goal of dissipating the loneliness they might feel in Israeli
society. The organization houses activity centers, organizes various social clubs and events
for participants, and provides individual and group psychotherapy when indicated. There are
Amcha offices in four major Israeli cities and several satellite branches scattered throughout
the country. This survey was carried out at the Amcha offices in Tel Aviv and in Jerusalem.
METHOD
Individuals who approached Amcha were telephoned by a clinical psychologist who
explained the survey and invited them to participate. The voluntary nature of participation
was made clear, and care was taken to prevent applicants from feeling obligated to participate. Applicants who agreed to participate then received a telephone call from one of the
interviewers (trained psychology graduate students) who made an appointment at a place,
either at their home or at the Amcha office, and time convenient for participants.
Target and Comparison Groups
A total of 88 people were interviewed between June 1998 and March 1999. Sixty were
first-generation survivors with an average age of 75 (SD = 3.0), and 28 were child survivors

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

192

Style file version June 4th, 2002

Brom, Durst, and Aghassy

with an average age of 64 (SD = 3.6). Fifty-nine percent were men, and 41% were women.
Seventy-five percent were married, 17.5% were widowed, and 7.5% were divorced. On
average, participants had 11 years of schooling (SD = 4.0).
Comparison Groups
Four comparison groups were used to provide a perspective of the scores of the target
group. The Child survivors group consists of 50 child survivors of the Holocaust, randomly
sampled from the Jerusalem population (Cohen et al., 2001). Secondly, and from the same
source, are 50 people from the population of Jerusalem, matched with the first group on age,
marital status, and cultural background (named Non-Holocaust survivors). The mean age
of these groups was 62, and the number of men and women in both groups was equal.
The third comparison group consisted of 800 psychiatric outpatients, consecutively
referred to the Community Mental Health Center of Herzog Hospital in Jerusalem. This
group filled out the Brief Symptom Inventory (BSI; Derogatis and Spencer, 1982). To
compare the World Assumption Scale (WAS; Janoff-Bulman, 1989) scores, another sample
of 169 psychiatric outpatients, consecutively referred to the same clinic, was also used. Of
both samples, the mean age was 34 (SD = 10); 56% were male and 44% female, 28% were
single, 57% married, 7% divorced, and 1% widowed.

Instruments
Generally accepted instruments, widely utilized in the trauma field, were used to assess
posttraumatic and general psychiatric symptomatology and cognitive coping styles. This
enabled a comparison of the target group to other groups in a quantitative analysis.
To assess demographic variables, a short questionnaire was administered inquiring
about date of birth, education, and marital status.
To assess general symptomatology, the BSI, an abbreviated version of Derogatis
SCL-90 (Derogatis, 1977), was utilized. It consists of 53-items, assessing general distress
and symptomatic behavior. Adequate reliability has been demonstrated both in the North
American (Derogatis and Melisaratos, 1983) and in Israeli populations (Canetti et al., 1994).
Evidence for satisfactory validity has been reported for the North American population, but
norms pertaining to the Israeli population are lacking. Therefore, only the average sum
score was used in this study.
To assess symptoms of posttraumatic phenomena, the Impact of Event Scale (IES) was
used. The IES, developed by Horowitz et al. (1979), is a 15-item questionnaire assessing
emotional responses to trauma along the dimensions of intrusion (i.e., unbidden thoughts,
flashbacks, emotional upheaval, or nightmares pertaining to the trauma) and avoidance (i.e.,
attempts to avoid activities, memories, feelings or thoughts associated with the trauma, and
emotional numbness). The questionnaire has been found reliable and valid in an Israeli
sample (Schwarzwald et al., 1987).
For an assessment of cognitive coping style, the WAS was employed. It consists of
32 items assessing eight basic assumptions people hold about themselves (i.e., their selfworth, the role of luck in their lives, to what extent they think they can exert control over
what happens to them), about other people (i.e., benevolence of people), and about the world

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

Style file version June 4th, 2002

Older Adult Holocaust Survivors

193

(i.e., benevolence of the world, the prevalence of justice in the world, how controllable life
events are, and to what extent life events occur at random). Participants obtain scores on
each of the eight subscales. Reliability and validity were found to be satisfactory in an
Israeli sample (Prager and Solomon, 1995).

RESULTS
Of the Amcha applicants approached, 59% agreed to participate. Telephone discussions
soliciting participation were often lengthy, as participants used this opportunity to ventilate
their present concerns. Some survivors recounted their wartime histories. Many reported
multiple major stressors following the war, such as death of children, spouse, and other
close family members, health problems, marital difficulties, and financial ordeals. Many
survivors described their present lives as lonely and isolated and reported that they had
negative relationships with their children. Some were dealing with family members suffering
from psychiatric problems, usually Holocaust-related. It appeared that many applicants
approached Amcha for help concerning their deplorable financial situation.
Table I summarizes the results on the BSI and the IES and compares the target group
with two other groups.
An overall MANOVA on the data of the BSI reveals that the groups differ in a statistically significant way on this measure (F = 42.6; df = 4, 640; p < .001). The picture that
emerges from post hoc Bonferroni comparison is that the survivors who turn to Amcha are
in acute distress. Amcha child survivors and psychiatric outpatients show the most severe
psychosocial suffering as measured by the BSI, followed by the group of Amcha firstgeneration survivors. Child survivors in the general population do not report significantly
higher levels of distress than do the non-Holocaust survivors, and these scores are within
the normal range.
Participants suffering the highest level of posttraumatic stress symptoms, as reflected
by the IES scores, are the Amcha child survivors and Amcha first-generation survivors.
Both groups report more intrusion and avoidance symptoms than do the nonclinical group
of child survivors. Even participants in this nonclinical group, however, whose mean BSI
score suggests an adequate level of adaptation, appear to be suffering considerably from
trauma-related symptoms in comparison to their controls. Their IES scores suggest that up

Table I. Brief Symptom Inventory and Impact of Event Scale

Amcha
First-generation
survivors
(N = 60)

BSI
Intrusion
Avoidance
IES Total

Child
survivors
(N = 50)a

Non-Holocaust
survivors
(N = 50)a

Psychiatric
outpatients
(N = 800)

SD

SD

SD

SD

SD

120.8
20.7
10.3
31.0

30.2
10.2
7.3
13.2

132.8
19.1
13.9
33.6

39.1
10.8
10.0
14.3

81.8
14.3
11.4
25.6

26.7
10.3
10.0
15.6

73.2
5.2
2.6
8.3

19.1
6.6
3.9
9.3

116.8

43.4

a A nonclinical group (N

2001).

Child
survivors
(N = 28)

= 50) of child survivors and a comparison group of 50 age-matched peers (Cohen et al.,

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

Style file version June 4th, 2002

194

Brom, Durst, and Aghassy

Table II. World Assumptions Scale
Amcha
First-generation
survivors
(N = 60)

Justice
Benevolence of
People
Randomness
Benevolence of
the World
Controllability
Self-Control
Self-Worth
Luck

Child
survivors
(N = 28)

Child
survivors
(N = 50)a

Non-Holocaust
survivors
(N = 50)a

Psychiatric
outpatients
(N = 169)

SD

SD

SD

SD

SD

9.8
14.6

4.0
3.5

9.3
13.7

3.5
3.2

10.4
16.2

4.1
3.1

8.9
16.5

3.2
3.1

12.5
16.1

4.0
3.9

16.4
12.9

2.9
3.9

16.6
13.3

3.5
3.3

14.2
15.1

4.1
4.3

13.5
13.8

4.7
4.0

13.2
14.9

4.9
4.3

14.5
16.8
15.5
13.8

4.0
3.2
4.1
3.9

14.7
16.0
14.3
14.3

4.0
3.7
4.8
6.1

14.2
16.2
18.3
15.3

4.1
3.8
4.0
4.0

12.5
16.1
18.8
13.6

4.4
3.5
2.9
4.3

14.9
16.2
14.9
12.7

4.2
3.9
4.5
4.3

nonclinical group (N = 50) of child survivors and a comparison group of 50 age-matched peers (Cohen et al.,
2001).

aA

to 50% of them may be suffering from chronic PTSD, based on a cutoff score of 26 for a
clinically significant level of PTSD.
Results for the eight WAS subscales are presented in Table II. An overall MANOVA
indicated that there are significant differences between participants (F = 3.8; df = 4, 280;
p < .001). Statistically significant differences in post hoc Bonferroni comparisons demonstrate the following about the group differences: Psychiatric outpatients and Amcha applicants perceive themselves as less worthy than nonapplicants to mental health facilities
(child survivors and their non-Holocaust survivors). In addition, Amcha first-generation
survivors perceive the world as less benevolent than do psychiatric outpatients.
The biggest difference on the Benevolence of People subscale was found between
Amcha child survivors and non-Holocaust survivors. Amcha child survivors view people
as less benevolent.
Psychiatric outpatients perceive the world as more just than do all other groups, and
they view the world as more controllable than do the group of non-Holocaust survivors.
The child survivors in the general population view themselves as lucky individuals, more
than the psychiatric outpatients. Amcha applicants, first-generation as well as child survivors, view negative events as occurring in a random fashion, more so than psychiatric
outpatients and non-Holocaust survivors.
To deepen the understanding of the relationship between psychosocial symptoms and
worldview, a regression analysis was conducted with the BSI score as the dependent variable
and the WAS subscale scores as the independent variables. In a stepwise regression analysis,
seven of the eight subscale factors (all except Self-Control) entered the equation and together
explained 44.7% of the BSI variation (F = 24.6; df = 1, 213; p < .001). This means that
cognitive coping patterns are related to the level of psychosocial suffering.
CASE HISTORIES
Clinical work with Holocaust survivors is quite challenging from many perspectives.
Although clear posttraumatic symptoms are always present, very often the existential and

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

Older Adult Holocaust Survivors

10:58

Style file version June 4th, 2002

195

relational issues are much more on the foreground. To balance the picture that might have
come out of the data, two case studies are also presented. The personal information has
been changed so that recognition of the clients is not possible.
Rachel
Rachel was born in 1925, in Lemberg (Eastern Poland), the eldest of four children.
Her father owned a bakery, and already, as a small child, she liked to play in the shop and
help out when there was a rush on Friday. The family was traditionalreligious. They lived
in a mixed gentileJewish neighborhood; the children went to a gentile school, and at home
they spoke only Polish. The German army entered Poland in 1939. The area in which they
were living was occupied by the Russians and was considered friendly towards the Jews.
Friends who fled from the Germans on their way to Russia urged Rachels family to leave,
but her father laughed at what he considered exaggerated and hysterical stories.
When the German soldiers overran their town in August 1941, steamrolling towards
Russia, Rachels family allowed relatives from neighboring villages to move in to their
home. Now, they heard the frightening stories about the rampage and killing, which took
place immediately after the occupation.
It did not take long before Rachels father and, shortly thereafter, her mother was taken
away to a slave labor camp. Thus, at the age of 16, Rachel became responsible for her
siblings. However, she could not save them from deportation. While on a transport, in 1943,
Rachel succeeded in jumping from a train, alone. She managed to roam from village to
village, living like a pariah. For certain periods she worked as an Aryan girl on a farm;
other periods she spent hiding in the forests, almost starving from hunger and cold. At the
liberation in the summer of 1944, she was 19 years old and alone.
During the years immediately after the war, Rachel was very much preoccupied with
thoughts about her family and tried desperately to locate any surviving relatives, to no avail.
Before her mother had been taken away, she had begged Rachel to look after the younger
children. Rachel felt much guilt about the fact that she did not succeed in saving any of her
siblings. Via the Displaced Person Camps in Germany, Rachel arrived in Palestine, married
a survivor, and settled with him in a town near Tel Aviv.
For many years, Rachel reportedly suffered from irregular menstruation, lower back
pain, and short periods of muteness, which later disappeared. As she had no formal education, Rachel started as an assistant in a kindergarten. After finishing her own schooling, she
became a teacher at a public school, where she stayed until her pension age. Since then, she
has continued to work on a half-time basis as a librarian.
Rachel and her husband badly wanted many children to replace the many losses they
had suffered. She had a few miscarriages and two stillborn children. These losses almost
drove her to desperation, but she did not give up. Against medical advice, she resumed
her attempts to get pregnant, and after many treatments and much suffering, two healthy
children were born. She saw this as a personal victory, and named the first-born Victor. The
couple devoted themselves to their childrens upbringing and did their utmost to make their
lives as happy as possible. Rachel believed that she managed to hide most of her memories
and feelings about the Holocaust from them. As she said, After a long struggle, the kids
were born, and I directed my life totally towards the future; I thought the past should be left
for the historians.

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

196

Style file version June 4th, 2002

Brom, Durst, and Aghassy

It was only after her grandchildren started asking questions that Rachel opened up and
conveyed to them the tragic events she had experienced during the Holocaust. Although
she reported feeling some relief at first, she soon became very sad, as those memories
from long ago started to keep her awake frequently. She described herself as a woman who
had previously always been dynamic and busy, a woman who never had time to be ill.
At this point, however, she started to feel that she was becoming old and frail. Her back
pains returned, and signs of diabetes and arthritis appeared. What frightened her most of
all, however, was the heart attack suffered by her husband, her companion for so many
years. Rachel began to feel insecure and became incapable of managing her daily errands;
her fighting spirit and energy were gone. She then turned to Amcha, saying, I am losing
control of my body and my life.
Commentary
Although Rachel did not fully elaborate on it, the impression is that she lived in the
shadow of guilt feelings because of her promise to her mother to look after her siblings.
Her determination to have children of her own was almost unbelievable, but she succeeded.
Although Rachels account suggests that she was outwardly always optimistic, active, and
smiling, she reported wondering internally how life could have been so cruel. For many
years, she did not reveal her inner pain and reportedly gave the impression that she had
mastered her Holocaust experiences. Eventually, however, she felt increasingly unable to
control the intrusive memories, which included feelings of much sadness, sorrow, and longing for her lost family. The trigger was twofold: on one hand, the grandchildren questioned
her frequently about her life and about the Holocaust, which brought back many memories
of the past; but worse than that, her husbands heart attack brought on the fear of being
left alone again. Rachel felt that with aging, and after the heart attack of her husband, her
strength and resiliency were waning. Becoming aware that she could no longer fight as she
previously did, she succumbed.
Yakov
Yakov was born in 1927, the second of three children in an assimilated family from
a small town in Poland. His father was the owner of a small factory. The family was well
established, and Yakov described himself as having been a spoiled only son, who got
whatever he wanted. In the beginning of the war, his father tried to find ways to flee
Poland with forged papers. The second time they tried to cross the border they were caught,
and, when his father attacked one of the soldiers, he was killed on the spot. Yakov witnessed
this traumatic event and did not understand whether his father acted out of heroism or despair.
The family returned to their home dumbfounded. Yakovs mother was desolate and was no
longer able to take care of the family.
In 1942, Yakovs family was transferred to a ghetto, where the three children had to
work in a factory outside. At the end of the day, the children had to cross a wooden bridge
to return home. Intermittently, SS-men would shoot at random at the returning children,
forcing them either to run or to stand still and then lay down. Their mothers would wail
about their fate, praying their child would not be that days victim. During one of these

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

Older Adult Holocaust Survivors

June 7, 2002

10:58

Style file version June 4th, 2002

197

games, his younger sister was shot and killed. In 1944, the three remaining members of
his family were sent on a transport to Birkenau, where his elder sister disappeared. From
there, he was sent with his mother to a forced labor camp in Germany. They went to work
every day in a factory. Then, 1 day in February 1945, he heard that his mother had died of
dysentery.
In April, the American forces liberated him. By this time, he was a man young of
age but, as he later stated, old of spirit. For some time, he wandered around, and, although he knew better, he still held on to a glimmer of hope that some of his relatives
might still be alive. However, he found no one. He felt that there was no one in the world
interested in his fate or his well-being. He felt he had learned a lesson, not to get too
close to or trust anybody. Instead, he decided to look after himself and be in control of his
future.
Yakov went to Palestine, enlisted in the army, participated in the war of independence,
and served until 1952, when he was discharged as a captain. He behaved as an Israeli,
speaking fluent Hebrew without the slightest accent. Yakov married a woman born in Israel,
and over the years two children and four grandchildren were born. The only information
he disclosed to his family about his background was that he was born in Europe. Relatives
were never mentioned, and, beside his wife, no one really asked about them.
Yakov was always busy and worked intensively. After a few unsuccessful starts, he
settled himself as an independent businessman, mostly dealing in importexport, which
demanded much traveling abroad. During the Holocaust, he had learned to relate only to
himself. His experiences helped him survive in the rough world. It did not take many
years before he could afford himself and his family a luxurious life, but even then, he did
not allow himself to slow down. On the contrary, he was never satisfied, never sure that he
had enough resources to support himself in old age and to insure the future of his children.
Later, when in therapy, Yakov admitted that he was not very interested in socializing.
He did not appreciate superficial small talk with acquaintances and preferred instead to sit
at home and read a book. He worked long hours but spent some time playing bridge, and
liked drinking selected wines. From a certain age on, he wanted to educate his children
according to his own strict rules. He thought they needed an example of how to survive in
this jungle and that, to become successful, they needed to obey him as soldiers would
their commanding officer. Formally, he was willing to discuss these matters with his wife,
but he always fought for his principles, telling her that his life experiences taught him what
was best for the childrens future. Sometimes, in therapy, Yakov complained about the fact
that his children kept away from him and did not accept his friendship. Although he always
said that he gave everything to his family, he did not agree that he withheld his emotions; he
perceived himself as merely controlling his emotions. Neither did he agree with his wife,
who said that he did not know how to build a normal family life or that he was a selfish,
difficult person with whom to live.
When Yakov was in his 50s, he had his first heart attack, but this did not change his
behavior. What hurt him and made him feel bitter was that his children, who both became
successful professionals, were not in contact with him anymore. Even when they needed
advice, they went to their mother.
Yakov became more secluded and did not grasp that his children felt persecuted by his
critical and cynical remarks. When he had to undergo a surgical bypass operation, only his
grandchildren visited him in the hospital. For the first time in his life, he felt defeated; only

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

198

Style file version June 4th, 2002

Brom, Durst, and Aghassy

now did he give in to the often-repeated demand of his wife to go for counseling. Yakov
agreed to join his wife to help her cope with the family crisis. It was then that he came to
Amcha.
Commentary
The traumatic experiences Yakov went through starting at age 14 were manifold.
Within the span of 4 years, he witnessed the killing of his next of kin, worked as a slave,
and was surrounded by humiliation, cruelty, and death. After the war, he started a new life,
accommodating to his new surroundings, and driven by an inner force to become financially
independent. In his business life, he did extremely well, but he lacked the ability to attach
himself to his new family. He was emotionally withdrawn, suspicious, demanding, and
incapable of empathic feelings towards his children. Being totally absorbed in his work, he
tried to impart the bitter lessons of the past to his children. He never mentioned his parents
or sisters and never showed any sign of emotions connected to his past. Overtly, he never
mourned his relatives; it was as if they had never existed.
DISCUSSION
The material presented in this paper depicts different aspects of the difficulties endured
by Holocaust survivors. Concerning the intensity of PTSD symptoms, we have confirmed
that they are tremendously high among survivors who apply for help, and are also considerably high among nonapplicant survivors.
The questionnaire scores indicate, as expected, that Amcha applicant Holocaust survivors suffer a higher level of posttraumatic stress than do all other groups to which they
were compared in this study. Amcha applicants, especially child survivors, appear to suffer a
comparable level of psychosocial distress to that of psychiatric outpatients. Because Amcha
advertises its establishment not as a psychiatric institution, but as a center or home for
Holocaust survivors, it was not expected that there would be such a high level of psychological suffering in this group.
The issue of personality changes in Holocaust survivors has not been studied systematically. Although the early research and clinical literatures note personality alterations
observed in survivors, not one study has ever examined this empirically. After the introduction of PTSD as a diagnostic category, research became both more focused and, at the same
time, more limited in its scope. The fallacy of a new diagnostic concept, PTSD, has been
blamed by some authors for the domination of thinking on psychopathology as the consequence of trauma: The concept of posttraumatic stress disorder has become so fashionable
that it is dominating the debate worldwide about human responses to catastrophic events
(Kleber et al., 1995). The almost automatic association between trauma and PTSD has
diverted attention from the possibility that totally different responses or response patterns,
such as personality changes, exist as well.
The clinical work with severely traumatized individuals has led to the development
of concepts such as Complex PTSD (Herman, 1992) and Enduring Personality Change
After Catastrophic Experiences (World Health Organization, 1992) in order to deal with the
gap between PTSD and clinical observations. Because of the lack of adequate diagnostic

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

Older Adult Holocaust Survivors

June 7, 2002

10:58

Style file version June 4th, 2002

199

concepts, some authors see the designation Chronic PTSD as the most suitable one to
describe the suffering of many Holocaust survivors (Kellerman, 1999).
It is our contention that PTSD is not and has never been suitable to describe the complex
constellation of symptoms that have been observed in Holocaust survivors. The deep-seated
injury and lack of basic trust, the extreme restriction of emotions, and characterological
difficulties (Krystal, 1981) are not adequately accounted for by the criteria of PTSD. Even
now, more than 55 years after the end of World War II, no diagnostic conceptualization
has been proposed that can cover the complexity of the clinical phenomena of help-seeking
Holocaust survivors.
Studying the worldviews of survivors and comparing them with other groups helps
to reveal some of the deeper traces of the Holocaust. It appears that there are connections
between the way respondents view the world and their level of psychosocial symptoms.
Generally speaking, a relationship was found between better psychosocial adjustment and
the following variables: a higher self-worth and a stronger belief in oneself as a lucky
individual; a strong belief that the world is a just, benevolent, and controllable place; and a
strong belief that negative events do not occur at random.
An explanation for the differences in worldview found among the groups studied
here may be suggested by Lerners Just World theory (Lerner, 1980). Lerner postulated
that many individuals cope with life by believing that justice prevails, that there is order or
reason behind the events in life, and that people generally get what they deserve; good people
therefore have good lives, whereas the less deserving suffer. People adhering to such beliefs
would be expected to score relatively high on justice, benevolence, and controllability of the
world, and low on randomness. In this study, this pattern was manifested most prominently
in the psychiatric outpatient group, more so than in the control group of normals, and more
so than in the group of Amcha survivors. It appears that psychiatric outpatients attribute
more justice, benevolence, and controllability to the world than do other respondents, and
see events, least of all other groups, as guided by randomness. One possible explanation
for this disparity is the fact that psychiatric outpatients are in need, more than communitydwelling adults, of an explanation for their distress, and, specifically, one, which indicates
that change, is possible. Psychiatric outpatients score low on self-worth. By seeing the world
as a just, benevolent, and controllable place, they may implicitly, according to the Just World
theory, believe that their present suffering is due to their unworthiness, and that if they
become more worthy as individuals, their lives will change for the better. Adhering to this
theory, then, may be seen as a cognitive coping style, or a defense, that affords psychiatric
outpatients a degree of perceived control, thereby helping maintain optimism and a lower
level of psychosocial distress.
Amcha applicants, on the other hand, fail to apply this defense. The most prominent
indication of this is that on randomness, they score higher than all other groups. This
demonstrates that they fail to perceive any order or reason behind events. They seem to
believe that anything can happen to anybody, at anytime, notwithstanding how worthy or
deserving that person is. This perceived randomness may generate feelings of pessimism,
helplessness, and futility.
Looking beyond the PTSD concept, the case examples illustrate some of the clinical
features typically found among survivors of the Holocaust. Although the cases of Rachel and
Yakov are very different in background, the common denominators are the severe traumatic
experiences and the way these traumatic experiences have become a main theme in their

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

June 7, 2002

10:58

200

Style file version June 4th, 2002

Brom, Durst, and Aghassy

lives. Both were sole survivors of their families and had an absence of overt mourning
reactions. In Yakovs life, there was massive use of intense denial of the past; the price for
this was a constricted life pattern and emotional detachment from his family. In Rachels
life, there were signs of posttraumatic reactions immediately after the Holocaust; thereafter,
she coped very well for many years. With aging, she slowly became more depressed and
had many intrusive thoughts.
In both cases, lifestyle is clearly influenced and characterized by the traumatic experiences. Both are overactive fighters with a profound sense of loneliness. Both strive to show
to the world around them their normalcy, whereas the inner pain is kept inside. Both present
an inability to accept weakness and wait until the suffering is very severe, before they ask
for help. In their pathology, the change and split in personality features is more striking than
the characteristics of PTSD; this becomes apparent in their behavior, in what they show,
but, even more so, in what they hide.
REFERENCES
American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders, 3rd edn.,
American Psychiatric Association, Washington, DC.
Antonovsky, A., Maoz, B., Dowty, N., and Wijsenbeek, H. (1971). Twenty-five years later: A limited study of the
sequelae of the concentration camp experience. Soc. Psychiatry 6: 186193.
Bastiaans, J. (1974). Het KZ-syndroom en de menselijke vrijheid (The concentration camp syndrome and human
freedom). Nederlands Tijdschrift voor Geneeskunde 118: 11731178.
Canetti, L., Shalev, A. Y., and Kaplan du Nour, A. (1994). Israeli adolescents norms of the brief symptom inventory
(BSI). Isr. J. Psychiatry Relat. Sci. 31: 1318.
Carmil, D., and Carel, R. S. (1986). Emotional distress and satisfaction in life among Holocaust survivors: A
community of survivors and controls. Psychol. Med. 16: 141149.
Cohen, M., Brom, D., and Dasberg, H. (2001). Child survivors of the Holocaust: Symptoms and coping after
50 years. Isr. J. Psychiatry 38: 313.
Danieli, Y. (1981). The aging survivors of the Holocaust: Discussion on the achievement of integration in aging
survivors of the Nazi Holocaust. J. Geriatr. Psychiatry 14: 191210.
Derogatis, L. R. (1977). The SCL-90-R: Administration, Scoring and Procedures Manual I, Clinical Psychometrics
Research, Baltimore.
Derogatis, L. R., and Melisaratos, N. (1983). The Brief Symptom Inventory: An introductory report. Psychol.
Med. 13: 595605.
Derogatis, L. R., and Spencer, P. M. (1982). The Brief Symptom Inventory. Administration, Scoring and Procedures
Manual, Clinical Psychometrics Research, Baltimore.
Eaton, W., Sigal, J. J., and Weinfeld, M. (1982). Impairment in Holocaust survivors after 33 years: Data from an
unbiased community sample. Am. J. Psychiatry 139: 773777.
Herman, J. L. (1992). Trauma and Recovery, Basic Books, New York.
Herman, K., and Thygesen, P. (1954). The concentration camp syndrome eight years after the liberation. In
Thygesen, P. (ed.), La deportation dans les camps de concentration Allemands et ses Sequelles, F.I.R., Paris,
pp. 5672.
Horowitz, M. J., Wilner, N. R., and Alvarez, W. A. (1979). Impact of Event Scale: A measure of subjective stress.
Psychosom. Med. 41: 209218.
Janoff-Bulman, R. (1989). Assumptive worlds and the stress of traumatic events: Applications of the schema
construct. Soc. Cognit. 7: 113136.
Kellerman, N. P. F. (1999). Diagnosis of Holocaust survivors and their children. Isr. J. Psychiatry 36: 56
65.
Kleber, R. J., Figley, C. R., and Gersons, B. P. R. (1995). Beyond Trauma: Cultural and Societal Dynamics, Plenum
Press, New York.
Krystal, H. (1981). The aging survivor of the Holocaust. J. Geriatr. Psychiatry 14: 165189.
Kuch, K., and Cox, B. J. (1992). Symptoms of PTSD in 124 survivors of the Holocaust. Am. J. Psychiatry 149:
337339.
Lerner, M. J. (1980). The belief in a Just World, Plenum Press, New York.
Niederland, W. G. (1971). Introductory notes on the concept, definition, and range of psychic trauma. Int. Psychiatry
Clin. 8: 19.

P1: GRA/GOQ

P2: GCO/GOQ

Journal of Clinical Geropsychology [jcg]

pp493-jocg-373717

Older Adult Holocaust Survivors

June 7, 2002

10:58

Style file version June 4th, 2002

201

Prager, E., and Solomon, Z. (1995). Perceptions of world benevolence, meaningfulness, and self-worth among
elderly Israeli Holocaust survivors and non-survivors. Anxiety Stress Coping 8: 265277.
Schwarzwald, J., Solomon, Z., Weisenberg, M., and Mikulincer, M. (1987). Validation of the impact of event scale
for psychological sequelae of combat. J. Consult. Clin. Psychol. 55: 251256.
Van der Hart, O., and Brom, D. (2000). When the victim forgets: Trauma-induced amnesia and its assessment
in Holocaust survivors. In Shalev, A., Yehuda, R., and McFarlane, A. C. (eds.), International Handbook of
Human Response to Trauma, Kluwer Academic, New York, pp. 233248.
World Health Organization (1992). International Classification of Diseases and Related Health Problems, Tenth
Revision, World Health Organization, Geneva, Switzerland.
Yehuda, R., Elkin, A., Binder-Brynes, K. L., Kahana, B., Southwick, S. M., Schmeidler, J., and Giller, E. L. (1996).
Dissociation in aging Holocaust survivors. Am. J. Psychiatry 153: 935940.
Yehuda, R., Schmeidler, J., Siever, L. J., Binder-Brynes, K., and Elkin, A. (1997). Individual differences in
posttraumatic stress disorder: Symptom profiles in Holocaust survivors in concentration camps or in hiding.
J. Trauma. Stress 10: 453463.