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^*Coordinator of Services for Holocaust Survivors, Jewish Support Services for the Elderly (JSSE), Montreal, Canada

Pages 135-144

Introduction 
My work with Holocaust survivors has been influenced by what Mills (1973) refers to as a "sociological imagination", which considers the interplay of an individual's history and biography with the economic and political institutions of the society in which he or she lives. My own social work practice has been enhanced by political activism at the Canadian Jewish Congress. I would like to suggest that the resources of comparative organizations be explored, and that, when possible, we link our clinical population with others. This paper focuses on eight items I have found helpful in formulating an agenda to meet the needs of elderly Holocaust survivors. 
 

Understanding Survivors' Resistance to Assistance and Factors which Contribute to their Vulnerability in the Community 
Survivors of the Holocaust rarely seek mental health or social service assistance and are often reluctant to accept help. Consequently, many of them lack knowledge of the resources available to them and do not know how to access and negotiate the system. The reasons for this reluctance to accept help are varied  Many survivors' lives are intricately interwoven with the values and belief systems inculcated from the now extinct pre-war communities, and retention of these basic values has influenced their attitudes to seeking help. Some survivors adhere to the Old World ethic of self-reliance and are proud, particularly concerning financial matters. Moreover, a common perception among survivors from Eastern Europe is that only those who are totally out of touch with reality seek mental health intervention -- in short, only those who are insane.  Psychiatric referrals are thus often refused, while those who accept them often experience feelings of helplessness, dependency and shame. These feelings can often be reframed, however, if the act of seeking help is viewed as a sign of strength and courage. 

Other reasons survivors stay away from community assistance include anger toward the general Jewish community for having stood by complacently while so many millions were murdered; the negative reactions and attitudes of the host community on their arrival; and the minimal help provided upon immigration. 

In general, survivors have fewer extended family members than the average individual. In the Montreal area, for instance, many survivors are the sole remaining members of pre-war nuclear and extended families. Those survivors now in their eighties, whose first families were murdered in the Holocaust, may have remarried after the war but many did not, or could not, have 
children.   This lack of familial support contributes to the survivors vulnerability in the community, which is further compounded by language difficulties. Older survivors have acculturated less well to societal norms than younger ones, and many speak only their mother tongue (generally Yiddish, Hungarian or Rumanian). This inability to communicate in the language of the host community renders them particularly vulnerable when obtaining services. 

Some survivors have a fear and mistrust of government bureaucracy. Some will seek assistance only from a Jewish agency.  This can pose service delivery problems, as has happened in the province of Quebec, where most health and social services are offered by government agencies. Some people refuse to approach the latter because of their mistrust of non-Jewish workers or because they will be identified in a central registry. For example, when asked to fill out a form and answer questions, one survivor experienced feelings similar to those induced by Gestapo interrogations, and another survivor refused to fill out a government application form for health insurance. These feelings of mistrust can be mitigated if the survivor is accompanied to the government agency by a trusted individual. 
 

Survivors in the Context of an Aging Population Interacting with its Social Environment 
When working with survivors, it is important to assess their interaction with their social environment. This involves assessment of their family network, social support systems (such as friends and community supports), socio-economic status and physical environment (National Advisory Council on Aging, 1991). 

Survivors do not live in a social vacuum. As members of a rapidly aging society, they are susceptible to the same societal problems that plague a substantial proportion of our elders. Gerontological research has indicated that "better health and functional status, higher socioeconomic status and greater economic resources are associated with higher levels of mental health and psychological well-being" (Hard, 1988). 

In a study conducted in Montreal, it was found that the economic situation of survivors was often poorer than that of Canadian-born Jews (Weinfeld, Sigal and Eaton, 1981).  It is therefore important to ensure that survivors have access to affordable housing, proper health care, pension benefits, adequate transportation and proper nutrition.  It is a myth that all survivors receive restitution payments from the German government making them financially 
secure. While many survivors do receive payments, many others do not. In recent years, there have been some important changes in the restitution laws. The United Restitution Organization provides information and legal assistance in the filing and processing of restitution claims. 

Viewing Survivors as Distinct Individuals 
The literature cautions us to view survivors as individuals and to keep in mind that there is no typical survivor (Kahana, Harel and Kahana, 1988; Rosenbloom, 1983; Sigal and Weinfeld, 1989). Survivors come from diverse European countries, and speak different ethnic languages. They differ in their religious, cultural and political beliefs as well as in their educational and socio-economic backgrounds.  The environments in which they survived the Holocaust are also diverse; and they coped, and are still coping, with the extreme stress of their experiences in different ways. Furthermore, they have adjusted to the aging process in different ways. 

Differentiating Between Holocaust-related Stressors and Present-day Ones 
We must not generalize about, prejudge or predetermine survivors' problems on the basis of who they are and what they have lived through. It is important to differentiate between Holocaust-related symptoms and/or stressors and present-day ones.  All too often there is an overemphasis on survivor syndrome symptomatology. Although we frequently see a reactivation of such symptoms when defense mechanisms are weakened, for the most part they do not prevent social functioning. 

I have been involved in a number of cases wherein present-day environmental and health factors were overlooked and survivors were consequently labeled paranoid or depressed. In all these cases, the individuals were referred to survivor support groups at our agency. In one instance, a woman was being harassed by a tenant and was afraid to leave her apartment; in another, a woman was being emotionally abused by her husband and required a referral to an elder abuse unit.  Two cases of misdiagnosis occurred in a hospital setting. In the first, the severe anemia of a survivor with a history of chronic depression was overlooked, and she was treated only with antidepressant medication.  In the second case, a mildly suspicious survivor accused her Polish social worker of anti-Semitism; her history was not explored, and she was labeled paranoid and delusional, and prescribed antipsychotic medication. 

It is important to be sensitive to stressors related to the Holocaust experience. One woman was sent a German-speaking homemaker by a government agency, and a patient at a psychiatric institution was encouraged to have electric shock treatment without explanation about the procedure. Both these women lapsed into a state of anxiety. 

Educating Service Providers 
It is important to train health and social service professionals, paraprofessionals, religious leaders and volunteers in the special needs of Holocaust survivors, their psychosocial functioning, their diversity, the organizations with which they are associated and the resources available to them -- especially the new restitution laws, 

Each of our survivor support groups are co-facilitated by a social worker and a family practice medical resident.  The doctors find that this training experience enhances their understanding and improves their treatment procedures. 

Identifying Gaps in Service 
In recent years, communities around the world have developed specialized services to meet the unique needs of aging Holocaust survivors (Fried and Waxman, 1988; Hassan, 1988; Giberovitch, 1992; Kinsler, 1988; Lemberger, 1993). As health professionals, we are required to do our utmost to mobilize community resources to ensure that the identified needs of survivors are met. Sometimes this entails facilitating the latter's access to health and housing facilities and ensuring a decent standard of living. Sometimes it necessitates the development of new programs, which may tax already extended budgets. 

Creative responses to this problem include the development of programs in collaboration with other community organizations. For example, our Tikvah Seniors' Group is run by three agencies (Jewish Support Services for the Elderly -- JSSE, the Nursing Home Day Center and the Jewish Community Center), and our survivor support and discussion group is operated jointly with the psychogeriatric clinic of the Mortimer B. Davis Jewish General Hospital. Dr. Harry Grauer, the director of the clinic, supervises the group.  This integrated community approach, adopted in a spirit of cooperation and collaboration with other organizations, has brought much-needed services to the community. The combined initiative has made it possible to break the cycle of loneliness, isolation and depression that many survivors experience. Additional needs continue to be identified and plans for the future include a drop-in center, a home stimulation program and the publication of a training manual for professionals. 

It is essential that survivors have access to programs which provide opportunities to bear witness. A number of Canadian cities have Holocaust Remembrance committees, museums and documentation projects. 

If I had to choose one wish for the future, it would be the establishment of a community wide research study to explore the unidentified needs of Holocaust survivors in different settings: the community, hospitals and long-term care facilities for the chronically ill. 

Vehicles of Communication 
Conferences such as this one are crucial. They enhance our knowledge, teach us innovative and creative programming ideas and provide opportunities for networking: Too many of us work in professional isolation within our respective communities. 

Another important vehicle of communication, established two years ago, is a newsletter aimed at individuals and agencies whose client populations include Holocaust survivors and their families. It is entitled "If Not Now...", and its editor, Sarah Freeman, is a social worker at the Baycrest Center for Geriatric Care in Toronto, Canada. 

Political Activism 
We must do our utmost to put issues of concern to survivors onto the agendas of local planning committees, where they will be incorporated into policy. For example, at the 23rd Plenary Assembly of the Canadian Jewish Congress in May 1992, the following resolution was submitted and adopted:

• The Canadian Jewish Congress calls upon Jewish social service and mental health agencies in the public and private sectors to provide adequate funding for specialized services to meet the unique needs of elderly Holocaust survivors (p. 10). 

Specialized services for Holocaust survivors must be recognized as a community priority. Historically, communities have not been responsive to survivors' unique needs. We now have the opportunity to redeem ourselves by helping to make the last stage of these individuals' lives as comfortable as possible. 

Benjamin Meed, the president of the American Gathering of Jewish Holocaust Survivors, made the following passionate plea at a 1992 conference for health professionals in Miami: 
Do not send us into old age, when our strength wanes, do not abandon us" [quotation from Jewish High Holy Day prayer. We have been sent into old age; that has been a blessing. We never expected it and so in a sense we never prepared for it. (p.21) 

He concluded:

• That is our challenge; it is the collective responsibility of the Jewish people. We must be our brother's keeper. (p.21).

Bibliography 

Canadian Jewish Congress. 1992. Amendments to Bylaw 66 and Proposed Resolutions to be Presented to the 23rd Assembly. Toronto. 

"Fried, H.; and Waxman, H.M. 1988. '"Stockholm's Cafe 1984: A Unique Day Program for Jewish Survivors of Concentration Camps". Gerontologist 28:253-255. 

Giberovitch, M. 1992.  "Specialized Services to Meet Survivors' Needs". If Not Now... 1(1):4. 

Harel, Z. 1988. "Coping with Extreme Stress and Aging". Social Casework 69(9):575-583. 

Hassan, J.  1988.  "The Survivor as Living Witness".  In: Proceedings of the International Scholars' Conference: Remembering for the Future: Jews and Christians During and After the Holocaust, pp.1093-1104. Pergamon, Oxford. 

Kahana, B.; Harel, Z.; and Kahana, F. 1988. "Predictors of Psychological Well-being among Survivors of the Holocaust". In: Human Adaptation to Extreme Stress: From the Holocaust to Vietnam, Wilson, J. (ed.), pp.171-192. Plenum, New York. 

Kinsler, F.  1988.  "The Loneliness of the Holocaust Survivor". Journal of Psychology and Judaism 12(3): 156-177. 

Lemberger, J. 1993. "AMCHA". If Not Now... 2(1):9-11. 

Meed, B. 1992. "Holocaust Survivors and Aging". In: Selected Proceedings of the First National Conference on Identification, Treatment and Care of the Aging Holocaust Survivor, pp. 16-21.   The Holocaust Documentation and Education Center, Inc. and the Southeast Florida Center on Aging, Florida International University, Miami. 

Mills, C.W.  1973.  "The Promise".  In: Radical Perspectives on Social Problems, Lindenfeld, F. (ed.), pp.4-12. Macmillan, New York. 

National Advisory Council on Aging.  1991.  Geriatric Assessment and Treatment: Members of the Team. Ministry of Supply and Services, Ottawa, Canada. 

Rosenbloom, M. 1983. "Implications of the Holocaust for Social Work". Social Casework 64(4):205-212. 

Sigal, J.J.; and Weinfeld, M. 1989. Trauma and Rebirth: Intergenerational Effects of the Holocaust, Praeger, New York. 

Weinfeld, M.; Sigal, J.J.; and Eaton, W.W.  1981.  "Long-term Effects of the Holocaust on Selected Social Attitudes and Behaviors of Survivors: A Cautionary Note". Social Forces 60:1-19.