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The National Israeli Center for Psychosocial
Support of Holocaust Survivors and the
Second Generation: Raisons d’Etre
*Chairman, Professional Steering Committee, AMCHA; Elie Wiesel Professor for Holocaust Studies, Bar Ilan University, Israel
A Yiddish word derived from the Hebrew meaning ‘your people’, AMCHA is the name of an Israeli organization that was founded seven years ago by Survivors for survivors. A voluntary organization for non-material psychosocial support, through four branches in the four main cities of Israel (Jerusalem, Tel Aviv, Haifa and Beersheva), and with the help of 75 mainly part-time professional employees, AMCHA carries out the following self-assigned programs: psychotherapy for individuals, families and groups; Support groups; intergenerational meetings; consultation to agencies; community work with the help of volunteers; and study days and training sessions for professionals and the general public.
Its goals are to provide a framework for mutual support, to aid memory processing, to help with the working through of grief, and to treat the psychological problems of survivors.
To quality as an AMCHA client, the applicant has to declare that he or she is a Holocaust survivor or a second generation member. However, the immediate problem need not be overtly Holocaust-related. Since its inception, AMCHA has dealt with over 2,500 cases of short-term, long-term and intermittent psychotherapy; at the moment, we have 1,100 active flies. The total number of professional hours spent on therapy, psychosocial activities and training amounts to 50,000 over the past three years.
The five main reasons for AMCHA’s existence can be defined as follows: the large number of survivors in Israel; the higher risk of their developing mental health problems; the recent changes in clinical focus and the new psychosocial needs of survivors; the deficiency of general mental health services in relation to specific survivor problems; and changing public awareness in Israel.
The Number of Survivors in Israel
There is no systematic registration of Holocaust survivors in Israel, but an approximation can be gauged from the General Register, namely, the number of immigrants to Israel from territories previously occupied by the Third Reich, who were born before 1943 and arrived after 1945. As of March 1992, the number in this category was 276,000. About 100,000 of them are child survivors, jugendliche Verfolgten. Including the arrivals over the past few years from the former Soviet Union, the figure is now closer to 300,000. Of those aged 65 and over, 45% are survivors of the Holocaust.
By rough calculation, the number of second generation members in Israel is between 500,000 and 700,000 individuals. Thus, in Israel, the total number of those directly and indirectly affected by the Holocaust comes to approximately 1 million people. Some of these are psychiatric cases, though most are non-clinical.
Mental Health Problems in Holocaust Survivors
In the early years after the Second World War, there were many cases of physical and mental invalidism among survivors. Many such sufferers have already died; others live as chronic invalids in institutions.
Within the non-clinical survivor population itself, we see the emergence of global late-reaction patterns which can be classified as follows social integration (often excellent); psychological restrictions and symptoms; late decompensation and breakdown; late grief work and spiritual transcending. In more detail, non-clinical survivors are social successes, well-adapted to Israeli society. They cope well, are sometimes even too restless, and show overcompensatory behavior. Many continue working after pension age (Robinson, 1990). However, a heavy psychological price may be paid for such success, including psychological inflexibility, anhedonia, problems with intimacy and lifelong symptoms.
As these individuals get older, besides a total breakdown, we also see a spiritual transcending of past traumas, sensitivity to the suffering of others, and a working through of their memories. They open up toward their grandchildren, the third generation, something which they could not do with their own children, the second generation (Dasberg, 1993).
Some epidemiological findings in non-clinical survivors
In 1950, five years after liberation, the sociologist Shuval studied refugees in Israeli refugee camps. Konzentrationslager (concentration camp) survivors were more pessimistic and anhedonic than other European refugees, who were generally more optimistic. However, the survivors were much better able to withstand the daily disappointments and setbacks that new immigrants inevitably encounter. The controls were “volatile’1, the survivors of the camps were “hard”.
“Hardening” is manifested in stubborn, anhedonic, but at the same time adaptational, behavior. Had we known what we know now, after more than 40 years, we could have predicted at the time what the main global reaction patterns would turn out to be.
Thirty years after liberation, within the framework of a large gerontological study, Shanan and Shahar (1983) compared survivors of the camps, people who had survived in hiding (apropos: this was the first time such people were acknowledged by researchers), and Israeli controls. The first two groups showed more cognitive restrictions, but were equally well-adapted, and indeed showed better goal-directed achievement behavior than ordinary Israelis. However, they were restricted, rigid and hard — not a small psychological price to pay for adaptation.
On analyzing large health surveys of industrial workers in Israel, epidemiologists Levav and Abramson (1984) and Carmil and Care! (1986) found that 40 years after liberation, Holocaust survivors suffer significantly more from psychiatric symptoms and emotional distress than do other Israelis from European backgrounds.
There are some other Israeli comparative studies, which I shall not mention here in detail (see Dasberg, 1987), but, to summarize some of the methodologically best-conducted work, we see that non-clinical survivors in Israel did suffer in the past and are still suffering today from more cognitive restriction, less emotional responsiveness, more emotional distress and more psychiatric symptoms. And although they have better instrumental coping, they have worse emotional coping. This is the typical post-Holocaust syndrome as present in non-clinical survivors in Israel today. Under added pressure, they may become a mental health risk.
So much for non-clinical survivors. Dasberg, Bechar et al (1994) compared hospitalized therapy-resistant depressives, with and without concentration camp backgrounds, using the method of matched pairs in a double-blind study. The post-concentration camp depressives were more aggressive, narcissistic and demanding, and needed more attention from the staff. In other words, once they become very ill, survivors may need more nursing staff.
Recent changes in clinical focus
After almost fifty years, there is a new focus to Holocaust psychiatry; this is due to aging survivors, child survivors reaching middle age, and the second generation coming of age. For example, aging survivors continue to show good social adaptation and coping ability (Kahane, Harel and Kahan, 1988), but with added stress and pressure, clinical aggravation and breakdown is witnessed (Dasberg, 1987; 1991). Common triggers for late crisis and breakdown are national existential threats, acts of terrorism, Nazi war trials — this was systematically studied by Dasberg and Robinson (1991) regarding the Demjanjuk trial — and the threat of death. With regard to the latter trigger, in Israel 18,000 men and women have died in battles, 74,000 have been crippled, and 50,000 families are eligible for support by the Rehabilitation Branch of the Ministry of Defense. Survivors and their families are equally represented in all of these categories. Other stressors include psychogeriatric crises, illness, moving to a new home and remaining alone.
Similarly, child survivors have become a new psychosocial issue, and a focus for clinical attention. In Israel there are over 100,000 survivors who were younger than 19 at the time of liberation; of them, 65,000 were under 15. This group of people was silent for 40 years.
In group meetings conducted at AMCHA with non-clinical child survivors (median age 57), it has become apparent that the similarities between concentration camp children and those children who survived in hiding are much more conspicuous than the differences. All are eager to process their memories, to search their often unknown origins. The groups deal with the survivors’ guilt, their recurring fears of abandonment, and their sadness, late grief and mourning.
These survivors exhibit tremendous vitality in raising their families, but all struggle with identity crises — this struggle being a special feature of aging Israeli child survivors. In lsrael in particular, the group identity was strong and rehabilitative but, at the same time, the children’s former identities were ignored, and their victimization strongly denied.
There are clinical problems in this age-group, as well (Dasberg, 1992a), such as depression, identity disorders and psychosomatic complaints, which are often not recognized by doctors for what they really are. This population may also suffer from decompensation, sometimes resulting in a total loss of earning capacity as a late consequence (up to 40-50 years later) of the Nazi persecutions suffered in childhood.
AMCHA reports that psychotherapy in such cases is beneficial, although no systematic outcome studies are available for this group.
Solomon, Kotler and Mikulincer (1988) followed up all cases of combat reaction to the 1982 Lebanon War. They found that after three years, the second generation combat reactors (mostly reservists close to 30 years of age) had not recuperated, whereas the other combat reactors from the same battles had. All had been able men before the war. This finding shows that extra stress car cause enduring pathology in the second generation.
In a comparative double-blind study, our own group (Dasberg, Brom and Kfir, 1993) found that non-clinical female second generation members over age 30 were more symbiotic with their parents, more depressive and more overprotective of their own children, the third generation. This correlated with the gravity of their mothers’ persecution experiences.
AMCHA believes that primary and secondary prevention is called for now for these people. This should be our task.
The Israeli Mental Health Service in Relation to Holocaust Survivors
Students of the Elie Wiesel Chair for Holocaust Studies asked Israeli psychotherapists, social workers and nurses to reopen the persecution histories of their patients (Dasberg, 1992b). We composed a rating scale to describe the psychotherapists’ attitudes to Holocaust issues: negative (over-) involvement was -2; turning away from trauma was -1; partial turning away was 0; facing and accepting was + 1; and transcending trauma was +2.
These studies showed a widespread “victimophobia” among therapists. There are, of course, notable exceptions, such as AMCHA’s specially selected and trained trauma therapists — which is indeed one of the organization’s raisons d’etre.
Changing Public Awareness in Israel
Another phenomenon in Israeli society at large is the breakthrough in its long-standing inability to cope with the firsthand tales and personal histories of the individual victims.
On a national and monumental level, there has been an acknowledgement of those who died in the Holocaust. Recently, we have witnessed a change in the image of Holocaust victims who are still alive. Individualization and rehumanization is taking place, and there is less massive denial of the victims’ victimization. The opening of the borders in Eastern Europe and visits to the actual sites have undoubtedly contributed to changes in public awareness. But mainly, the inner psychological) borders and defenses within Israeli society have been broken down.
Of least importance for the changing public awareness are the added clinical problems that survivors now face. These remain for us, the mental health professionals, to deal with.
Taking these five factors together — namely, the number of survivors in Israel, their higher risk of developing mental health problems, the shift in clinical focus, the deficiencies in existing services and the change in Israeli public awareness — we arrive at a super-saturated mixture of factors, all of which demand action. This action was taken seven years ago by the founders of AMCHA; the organization fills an important lacuna in existing services.
However, the proof of the pudding is in the eating, and in what we have managed to accomplish. We were able to define 13 different target groups, each demanding a specific strategy and area of expertise. We also defined research needs in the areas of personality studies, diagnosis, epidemiology and service delivery, and we began to conduct follow-up and outcome studies of individual treatment implemented at AMCHA.
Within the survivor population, the main target groups(Dasberg, 1990) are non-clinical elderly survivors; psychogeriatric crises syndromes, including depression in elderly survivors; middle-aged child survivors; Russian immigrants (multiple massive trauma); and very orthodox religious survivors.
Target groups within the second generation are divided into the old second generation, born in the early post-war period; the young second generation, mostly born in Israel; those second generation members who have recently come to live in Israel from America, for example; and heavily traumatized, clinical second generation members.
Other target groups include the spouses of first and second generation members, the third generation, members of helping professions, and trainees specializing in post-trauma treatment.
The problem of financing is always the crucial question in preventive psychiatry and community mental health. There are no special insurance policies over and above the ones already in existence for Israeli Holocaust survivors.
Those who receive a special allowance from a former Third Reich country may see a private practitioner. Since 1988, AMCHA has offered Israeli survivors and their families subsidized services, but our resources are limited. In 1994,20-25% of our budget came from client fees, and close to 13% from government subsidies. The remaining funds came from our endowment and donations from abroad, primarily from the Netherlands, Germany and Austria, and from a number of other sources.
In conclusion, after seven years of experience, we may add to the original reasons for AMCHA’s existence an increase in public demand; accumulated evidence of positive therapy outcomes (systematic outcome studies have been conducted); and AMCHA as a center for specialized training.
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