Holocaust Teacher Resource Center

Support us by buying from the following:

Constant Agony*

Pages 53 – 64

An Integrative Psychotherapy of an Adult Child Survivor
Dr. Aviva Mazor; Dr. Yitzhak Mendelsohn


This paper focuses on a child survivor of the Holocaust, now middle-aged, who, for the last three years, has participated in a complex therapeutic setting combining individual psychotherapy with a couple therapy.

Child survivors of the Holocaust are defined as those survivors who, at liberation in 1945, were between the ages of one to sixteen years old, and whose ages at the present time (1995) range from the late forties to the early sixties (Dasberg, 1992).

Throughout the child survivor’s life he or she narrates an individual experience of survival and suffering caused by the continual breaks and losses in life’s sequences. The child survivor described in the following case-study has lived his adult life suffering painful losses and continual life crises, as though repetitively enacting his unknown, unremembered, and undiscoverable past, showing similarities to his way of being as a hidden child in the war, from the age of three years to eight years old.

For the last fifteen years, psychotherapy with adult child survivors has received special attention as a result of the pioneering and significant work of H. Keilson (1992), J. Kestenberg (1972, 1982, 1983, 1986, 1987), Gampel (1988, 1989, 1992), Laub (1993), Hogman (1985), Dasberg (1992), and other scholars. Such work emphasizes the following implications: First, the unique experience of children who survived concentration camps, ghettoes, being hidden in different locations, suffered long-term effects on their adult lives and on that of subsequent generations. Second, the main processes dealt with in child survivor psychotherapy refer to problems of identity: living with an undiscoverable past, problems originating from grief and mourning responses, and clarifying hidden feelings such as confusion, shame, split loyalties, terror and persecutory states. Individual psychotherapy was the main therapeutic process reported in most of these cases.

There are two purposes to this presentation: first, to describe an integrative therapeutic process conducted with an adult child survivor and his spouse, and the facilitative junctions that therapy provides between present issues and past losses. Second, to raise certain questions regarding therapeutic implications for adult child survivors who re-enact their traumas in adult life.

Before proceeding with the description of the therapeutic process, we will recount some details of Mr. L’s life history, as he related it to us during the past three years of therapy. Mr. L. learned from his cousin’s stories that he was brought up in a loving and affluent family, in a Western European country, until he was three years old. He does not remember them, but speaks continually of his longing for his lost family (killed around 1942-43). When he was three (in 1941), he was separated from his parents and older sister and sent to another country, in a way unknown to him, where he spent almost two years in hiding, every once in a while being transported from one family to another. His memories are of being constantly on the run, knowing instinctively how to adapt himself to the demands of adults: being presented as a grandson (he does not remember any other children), being hidden in attics, haystacks, under the house, or in closets. He remembers terrible scenes of darkness, cold and loneliness. Some couples would allow him to sleep in their bedrooms only late at night. When he was five years old he was sent to an orphanage and stayed there for three years, suffering dreadfully from the brutality of the other children and beating by teachers.

After liberation, when he was eight years old, he was rescued by his uncle (his father’s brother) and aunt, and once again he was moved to another country. They adopted him legally and he loves them very much. During therapy he refers to them as his parents and calls his uncle “father.” They were the first to explain what had happened to him during the war, although from time to time he also visited psychiatrists because of his nightmares, depressions and frequent panic attacks.

During his adolescence the family emigrated to another European country, where he completed his high school and university education. In his adult life, Mr. L. has been married and divorced three times. The first marriage lasted seven years and they had two children; he lost contact with this family years ago. His second wife drank herself to death and their son was legally adopted by his wife’s parents; this son is now in his mid-twenties and has a daughter. His third marriage was to a divorced woman with three children, but he could not bear the emotional burden of this family. He ran a successful independent business until he collapsed as a result of heavy drinking. He then decided to leave everything and “to immigrate to Israel in order to die here.” He came to therapy after being almost seven years in Israel. When he started treatment he spoke no Hebrew, was fired from his job, and was still a heavy drinker.

The Therapeutic Process

The following description will distinguish between four phases of the treatment, as we reflect on this process retrospectively. The initial phase of Mr. L’s therapy started when he was brought to the AMCHA clinic by his companion (a woman whom I call Ms. N). This visit was preceded by two weeks of psychiatric hospitalization, initiated by Mr. L, which were intended to start a weaning process from his heavy drinking. He seemed immersed in a deep depression with slow motor movement, uncontrollable trembling, and deep sadness. Speaking in a very slow whisper, he told us of states of panic attacks. Ms. N. expressed her unequivocal devotion to Mr. L. She wanted to save and help him, on condition that he overcome his alcoholism.

We decided to create a combined treating process for rehabilitative purposes. This included a once-weekly therapeutic meeting with both Mr. L. and Ms. N, regular meetings with the clinic psychiatrist who would take charge of the medication, and Alcoholics Anonymous group meetings.

During the first two years of therapy all meetings were analyzed and discussed with the second author to create an on-going diagnosis of Mr. L’s state. In addition, this setting allowed maximum flexibility in shaping the therapeutic environment according to changes needed by the patient. Another aim of the initial phase was to strengthen and support the companionship of the couple for, in this therapeutic setting, Ms. N. had the important function of holding, containing, as well as regulating, Mr. L’s helpless and dependent states.

During this phase, Ms. N traveled abroad for a month, and an alternative support system was arranged. This separation provoked an intensified depressed state, because of Mr. L’s fear of drinking again, his floods of anxiety, and feeling of mourning caused by separation from Ms. N. During that month we learned that the rehabilitative setting can provide the holding required. In addition, we realized that Mr. L., with much effort, completed all the daily tasks Ms. N. had left him. He could refer to his own feelings through issues brought up in AA meetings, expressing mainly the struggles of others to stop drinking and the depression and fear attached to this process. The junction of “mourning the bottle,” and the separation from Ms. N. disclosed his own mourning feeling that we could link to childhood memories of loss of parents, longing for them, and the price he paid for survival.

From the beginning of therapy we had many questions regarding Mr. L’s ability to respond to the therapeutic process and the function of Ms. N. within the therapeutic setting. Gradually, we discovered that Mr. L’s capacity to use therapy was closely connected to his ongoing relationship with Ms. N, her organization of their daily activities, and their companionship revealed in the therapeutic sessions. It seems as though the compulsive repetitive enactment that Mr. L. uses throughout his life came to light. But this time, through the therapy, we could give meaning to his moods and actions.

The second phase evolved after almost four month. Mr. L. continued to suffer from depression and obsessive fear with regard to his unemployment and constant trembling. On Ms. N’s return, she resumed her commitment to Mr. L. She handled all his medical activities and daily tasks, and had sufficient patience and hope to nurture him. She expressed surprise and delight at Mr. L’s improved coping with his drinking problem, in his accomplishment of daily activities, and in the treatment (although she criticized the slowness of its progress). Despite some complaints, she represented containing and motherly functions, and the more she trusted us, the more calm she became, and so helped Mr. L. to regulate his daily life. Ms. N gave no sense of competition or jealousy, and after a while it seemed that Mr. L. also trusted us. Participation in the therapy enabled her to hold him in the intervals between sessions, as if she had become a therapeutic extension as well as a therapeutic figure.

We discovered that Mr. L. could work on intrapsychic issues in the therapy within this relational context. For instance, by the end of the first year, Ms. N. decided to handle Mr. L’s eligibility for compensation. With the help of the clinic’s lawyer, Mr. L and Ms. N decided to travel to Mr. L’s home town. He saw this trip as an opportunity to search for. his lost roots. In the therapy, preparation for this trip disclosed further connections between childhood wartime experiences and the meaning of his depressive states and losses in his adult life. Through therapy the search for his identity in the past was located in the Holocaust, and he discovered that he belonged to the group of hidden child survivors. In the therapy, it was possible to give other meanings to the act of taking this trip. After the trip, Mr. L. suddenly told us that he had transferred from an English-speaking group to a Hebrew-speaking group at AA, and identified better with them. He spoke a lot about returning to work. This was another action that allowed me to give a meaning to his arrival in Israel, other than the original meaning he had presented.

During the third phase of treatment (in the second year), it became possible to discern the complexity of Mr. L’s daily life. When he could accomplish certain functions, other destructive functions became active almost simultaneously, revealing his continuous vulnerability. For example, the couple’s relationship gradually shifted from being complementary and dependent to one that was more symmetrical and reciprocal. In addition, Mr. L decided to live permanently with Ms. N, and sublet his own apartment (as if formalizing the reciprocal adoption).

A month later, he became very anxious and depressed; he was unreliable regarding his medication, and felt as though he were becoming insane. He overcame this short episode, but it was important to refer to the theme of adoption in his life. This theme encompasses simultaneously his state of survival, the death of his parents, and all subsequent losses in his life. While hiding during the war, and especially when his uncle legally adopted him after the war, the adoptive state, though saving him, also immersed him in his parents’ death. This untransformed situation of loss and adoption was compulsively repeated in his adult life by marrying, having children, and then leaving them.

Due to his past memories, we tried in his therapy not only to link these states, but also to differentiate between them; that is, not only to recognize the losses that accrue to the survival of the adopted child, but also to recall and reinstate his present adult relationship. Nevertheless, this crisis left us with many questions regarding aspects of his life that cannot be transformed.

Another theme that became very important in the second and third phases discloses once again the improvements that occurred in the therapy, but that left us with further questions of what could be represented rather than enacted.

From his initial phase of treatment, Mr. L’s trembling was very obvious. At first, we thought it was caused by alcoholism, but the emotional function emerged when Mr. L complained that when Ms. N. went abroad his trembling intensified and tortured him. His first thought on waking was to see whether he was trembling. He was especially ashamed and frightened when holding hands at A.A. meetings in case they might think he was still drinking. In addition, he felt that in such a physical state he could not go to work. However, almost half a year into treatment, Ms. N mentioned that Mr. L did not tremble during sessions, but started trembling again afterwards. We saw this as a sign that treatment was limiting the organizational function of his trembling. Mr. L dredged up more and more recollections of the past; he said that he recollected this trembling every since he remembered himself. We linked the trembling to the state of being on the run, very lonely without adult protection, using the Hebrew idioms “trembling with fear,” and “shivering from cold.” He remembered these states of being from his hiding places and the orphanage. Later, we linked it to trembling caused by alcoholism, and the continuous movement in his life, moving from one place to another, from one country to another, from one language to another, from one family to another. By the end of the first year. Mr. L, with help from Ms. N, sought help from a neurologist who almost totally eliminated this trembling. However, soon after his trembling disappeared, Mr. L started to complain of chest pains and an inability to breathe.

Mr. L explained that for years alcohol had been the only solution that had helped him control his trembling. It became clear that there were states in Mr. L’s life that, without the presence of Ms. N as a partner holding and supporting him, and without the therapy that gives meaning to his actions and suffering, he would not have been able to deal with these issues individually.

Another example occurred during treatment when Ms. N complained that Mr. L stood for a long time in front of the mirror slowly combing his hair. He could not explain why, but it was another opportunity to talk about bodily deprivations. We interpreted his action as the lack of a mother (or parent) who caresses and fondles her child and expresses her delight in him by gratifying the child. It was also a state in which he could appreciate that he was alive. Once again an inexplicable state combined vitality and loss, and he was compelled to produce this state for himself. After a few more sessions, Ms. N said that Mr. L was spending less time on this habit. We thought that it was not only the interpretation, but also the improvement of their spousal relationship that had made it less necessary.

During the fourth phase, the depressive moods subsided considerably, and Mr. L raised the theme of the repetition in his life of his aggression and power of self-destruction. His return to work became an important topic in therapy. He found a job in his own field of expertise after doing voluntary work, and his medication was reduced. The couple’s relationship presents many conflicts around issues of dependency and independency, his responsibility for remaining with Ms. N as a partner, and his continuing the relationship rather than breaking it up.


The Holocaust has caused tremendous destruction to its survivors, not only at the moment of catastrophe, but throughout their lives. For many survivors, their traumatic experiences require constant confrontation and struggle with its long-term effects, even fifty years later.

The integrative therapeutic process we depict highlights the complexity and difficulty of child survivors who continue to suffer in their adult lives. The combination of couple therapy together with individual therapy, attempts to provide the facilitating processes for the child within the adult survivor, as well as for the adult who continues to live within his surviving child.

Winnicott (1971) states that “trauma implies a break in life’s continuity, so that primitive defenses become organized to defend against repetition of ‘unthinkable anxiety’ or a return of the acute confusional state that belongs to disintegration of the ego structure” (p. 114). Children in the Holocaust suffered constant breaks in their life sequences, accompanied with unthinkable anxiety originating from external circumstances and inner confusional states. Keilson (1992) and Lifton (1979) add unique meaning to the survivors of massive social violence: “For what is broken -shattered – is the experience of life and the construction of vitality” (Lifton, p. 179). More specifically, according to Lifton, the survivor has a direct bearing on issues around death. Accordingly, the survivor is one who has been in contact with death in some bodily (physical) and psychic fashion, and remained alive. There are a few characteristic themes in the survivor such as the death imprint, death guilt, psychic numbing, conflicts regarding nurturing and contagion (infecting others), and struggles with meaning. All the characteristics affect the most profound levels of the survivor’s experience.

For our case study, we refer to the degree of anxiety associated with characteristics that have to do with the impossibility assimilating the radical intrusion of states of threat or end to life, which are a constant situation of the hiding child who has been on the run. In addition, “the child is less well equipped to deal with loss, while the adult has greater socio-cultural images of and symbolic investment in the capacity to experience both suffering and renewal” (Lifton, p. 188). Thus, the adult child survivor lives in states of being that can neither be transformed or cast aside.

Consequently, these states of being are revealed through persistent actions, moods and behaviors, without the individual’s capacity to reflect on their life-long influence. The terrible duality of these action states and behaviors is that they function simultaneously as an unrecognized reminder of the irreplaceable lost past, and perpetual, sometimes ineffectual, activities against loss. They are similar to the dual function of post-traumatic memories, which become an avenue of return to the source of living, but which also reactivate feelings of loss, helplessness and abandonment (Auerhahn and Laub, 1984; Klein, 1987; Lifton, 1977; Kestenberg, 1987).

Adult child survivors who were very young during the war and are left without recalled memories of their childhood before the war, start their life histories with the traumatic experiences of the war. One continues to struggle with the question: When life’s memories start with the unbelievable and incomprehensible experiences of the Holocaust, what can be assembled in the passages and crises of later life to restore life’s continuity and vitality?

*Paper presented at the conference, “Children, War and Persecution,” Hamburg University, September, 1993.


1. Auerhahn, N.C., and Laub, D. (1984). “Annihilation and Restoration Post-Traumatic Memory as Pathway and Obstacle to Recovery”, Int’l Jnl of Psychoanal., 11:327-344.

2. Dasberg, H. (1992). “Child Survivors of the Holocaust Reach Middle-Age: Psychotherapy of Late Grief Reactions”, Jnl of Social Work and Policy in Israel, 5-6:71-83.

3. Gampel, Y. (1988). “Facing War, Murder, Torture and Death in Latency”, Psychoanalytical Review, 75.

4. _________. (1989). “I Was a Holocaust Child”, in Wilson, A. (ed.) The Holocaust Survivor and the Family

5._________. (1992). “I Was a Shoah Child”, Brit Jnl of Psychotherapy,

6. Hogman, F. (1985). “Role of Memories in the Lives of World War II Orphans”, Jnl of the Amer Academy of Child Psychiatry, 24:390-396.

7. Keilson, H. (1992). Sequential Traumatization in Children. JM: Magnes.

8. Kestenberg, J.S. (1972). “Psychoanalytic Contributions to the Problem of Children of Survivors from Nazi Persecution”, Isr. Ann. Psychiatry and Related Disciplines, 10:311-325.

9._________.(1982). “A Metapsychological Assessment Based on an Analysis of a Survivor’s Child”, in Bergman, N.S. and Jucovy, M.E. (eds.) Generations of the Holocaust. NY: Basic.

10. (1987). Imagining and Remembering. Unpublished manuscript.

11. _____________ and Brenner, I. (1986). “Children who Survived the Holocaust”, Int’l Jnl of Psychoanal., 67:309-316.

12. _____________ and Gampel, Y. (1983). “Growing Up in the Holocaust Culture”, Isr. Jnl of Psychiatry and Related Sci., 20:129-146.

13. Klein, H. (1987). “Life Under Existential Threats — 40 Years After the Holocaust — Therapeutic Aspects”, Sihot, 1:94-97.

14. Laub, D. and Auerhahn, N.C. (1993). “Knowing and Not Knowing Massive Psychic Trauma: Forms of Traumatic Memory”, Int’l Jnl of Psychoanal, 74:287-302.

15. Lifton, R.J. (1977). “The Sense of Immortality”, in Feifel, H. (ed.), New Meanings of Death. NY: McGraw-Hill.

16. ____________ .(1979). The Broken Connection. NY: Simon & Schuster.

17. Winnicott, D.W. (1971). Playing and Reality. England: Pelican.
1 Paper presented at the conference, “Children, War and Persecution,” Hamburg University, September, 1993.