Working with Survivors of the Holocaust
and Elderly Survivors of Other Trauma
The Holocaust continues to impact aging survivors: Historical summary ............................ 2
Minimizing inadvertent re-traumatization in medical settings: ……………………….………….3
Behavior suggesting a person may have suffered earlier trauma: ..................................... 6
Interventions in clinical settings
Challenges for relatives feeling responsible to provide care
Feelings evoked in staff working with trauma survivors ............................................................ 7
Implications for Care. ............................................................................................................... 8
References and Selected Bibliography on the Holocaust
Web Links to Other Resources ……………………………………………………………………… 9
Characteristics & History of Aging Holocaust Survivors……………………… ………………11
Needs of Aging Holocaust Survivors ……………………………………………… ……………..12
Child Survivors……………………………………………………………………………………….. 12
Issues of the Second Generation …………………………………………………………………. 13
The Holocaust in context with other Genocides…………………………………… ……………13
Rescue and Protection ……………………………………………………………………………... 14
Caring for Aging Survivors of Other Trauma………………………………………… …………. 14
We invite you to share case examples and effective interventions in confidence
Informal Consultation Available
Related broadcast reports can be heard through computer links:
National Public Radio’s 12-minute report about our work
on "All Things Considered" on December 19th, 2002.
PRI's The World 5 minute report August 1, 2007 "Help for genocide survivors”
Baycrest Geriatric Center, Toronto, on care for Holocaust survivors:
WBEZ, Chicago: A Holocaust Survivor Hands Off Her Story, April 16, 2009
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Holocaust Survivors - History Matters
The Holocaust is the term for the effort made by Hitler’s Nazi Germany and their collaborators from all over Europe
to kill all the Jews. In old Greek ”holokauston” was a religious sacrifice burnt completely by fire. The Holocaust was
unprecedented: Nazi ideology called for the murder of all Jewish people (Bauer, 1984). Almost 6,000,000 Jews - 1½
million children - were killed in the Nazi years 1933 – 1945. This was ⅔ of the total Jewish population in Europe.
From 1941 on as the German army invaded the Soviet Union, SS Einsatzgruppen special duty troops gathered and
shot 2 million Jews into ditches. And from almost all of Europe, Jews were crushed together in rail cattle trucks for
days with no food, water or sanitation and transported to ghettos or directly to death camps in Poland. Of the 6
million Jews killed, about 500,000 died in ghettos and as victims of random terror and reprisals. 3½ million Jews were
sent to death camps where most were murdered in gas chambers, their bodies burnt after dental fillings and hair
were stripped for re-use (Dawidowicz, 1981).
Four death camps, Belzec, Chelmno, Sobibor and Treblinka, were set up to kill all Jews on arrival. Majdanek and
the Auschwitz-Birkenau complex were killing centers that also had many sub-camps for slave labor. Some of the
healthier-looking adults and older children, but not more than 10-20%, were ‘selected’ to be worked to death. Most
of those sent to work in Auschwitz-Birkenau (and only there) had numbers tattooed on their forearm. [If you notice
survivors with a tattoo, take your cue from them as to whether they want to talk about it.]
Other victims killed by Nazi persecution included at least 250,000 Gypsies (the Roma/Sinti), and about 170,000
physically or mentally impaired. 2,000 Jehovah’s Witnesses died from sickness and severe conditions in labor
camps because they refused to recognize the sovereignty of the Nazi regime to obtain their release. Many political
prisoners died in detention, as did many homosexuals – some were in camps over 10 years. About 3 million Soviet
prisoners of war who should have been protected by the Germans under the Geneva Convention were left to starve
to death or died from brutality, exposure, summary execution; some were gassed.
Survivors of the Holocaust – or the ‘Shoah,’ to use the Hebrew word for Disaster – are those Jews who were targets
of the Nazis and were not supposed to survive. They endured inadequate food (many during years critical for
growth), being deported and forced to live and work as slave laborers – for years – and the horror of death marches
as the Nazi Third Reich collapsed. Some others were protected, hid in cramped spaces or changed identities. Some
fought with partisans in the resistance. Some lived rough in the forests. Many got to the Russians in the east, and
were sent to labor camps in Siberia. Other people could leave before the war began in 1939 or in the early years, and
had different hardships including worry over family members. Some eventually joined the allied forces fighting
Germany. Many of those who came more recently from the Former Soviet Union have terrible stories of the Nazi
onslaught in Russia, Ukraine and other republics. And after Germany’s defeat in 1945, survivors in the FSU had
years when their identity as Jews could cause problems at work and in education and other areas of their life.
All those who lived through the Nazi “Final Solution” had unique individual experiences. Many were very young then.
After liberation survivors met silence, avoidance and limited support. Despite more hardships, many made families
and adapted with determination to new countries, learning new languages, and they made successful lives.
Reaching advanced age can present extra problems for survivors now when they may be more isolated, have less
distraction for bad memories and may be less able to cope independently. Behavior that now seems difficult might in
those terrible times actually have helped save their lives.
Survivors of any trauma can sometimes act differently from other people, and some never disclose their history.
Circumstances that are routine for most people can “trigger” disturbing old memories – and this may be especially
difficult for those with confusion or dementia. It can be as if the unspeakable events are happening all over again,
and this can provoke strong reactions – apparently out of the blue. The survivor may not be in control of the feelings,
or may lose the ability to find the words in English. Once such undesirable memories and reactions are aroused it
may not be clear that it is old trauma that is causing the present response. And trying to explain the differences
between the past and the present may not reduce the distress.
Any traumatic experience can cause extreme reactions, and all unusual behavior changes need careful assessment
and a caring response. If you observe a remarkable change in behavior, consider whether past trauma could be an
explanation. This may help you to respond sensitively and support the dignity of the person in distress.
If you notice behavior that concerns you, please promptly consult a supervisor
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The Impact of Early Trauma on Present Life:
Stress “Triggers” and Responses to Minimize Re-trauma
Facing illness or hospital care; Medical or dental procedures
Reason: When prisoners in Nazi concentration camps seemed ill they were sent to be killed because
they could work no longer and were therefore of no use to the camp economy. Others were ordered to the
“hospital” where they were in danger of horrible medical experiments, or left to die.
Today some survivors do not trust medical care and hide real concerns or pain. They may resist giving
blood or urine specimens. Injections can remind them of having a number painfully tattooed by a needle.
Undressing and exchanging personal items for an undignified hospital gown can raise anxieties about
property being returned. Hospital I.D. wristbands may remind them of being reduced to mere numbers
tattooed on the arm. Being shaved for a medical procedure can be a reminder of the crude shaving of
body hair on arrival at a camp. General anesthesia and medicine like morphine for pain may cause
disorientation during recovery from surgery, and distressing memories or dreams can lead to a patient
lashing out physically or verbally. Being physically restrained, isolated or confined may cause extreme
Interventions: Understanding and measured reassurance may help to manage anxiety, together with a
clear, unhurried explanation of each step in treatment. Like us, the survivor can detect genuine caring.
Choosing I.V. sedation or epidural anesthesia may lead to less anxiety and disorientation than a general
anesthetic. Survivors should not be left unattended – hospitals can arrange a person to sit with a patient.
White lab coats or uniforms
Reason: People in uniforms mistreated civilians horribly. So-called “doctors” in white lab coats selected
inmates for death and also performed cruel medical “experiments”. Gowns and your personal protective
goggles and gloves may now be reminders of unspeakable de-humanization.
Today anyone wearing any uniform – a police officer, doctor, postal worker or maintenance staff – can
awaken a survivor’s terrifying memory. The survivor may not realize, and may not be able to put it into
words, and the official has no idea why the survivor is reacting in a strange way. Staff should be aware
that survivors of the Holocaust and of other trauma can suffer unexplainable flashbacks.
Interventions: Be aware of a person’s history, and anticipate possible stress. If hygiene precautions
allow, remove lab coats, avoid uniforms and wear ordinary clothes.
Commanding voices; handling individuals roughly or with force; limits on freedom.
Reason: Guards, soldiers and police in ghettos and concentration camps routinely abused prisoners.
They pushed, pulled, yelled and forced captives to obey, rarely speaking kindly.
Now when a survivor is physically controlled or restrained by locked doors, it may bring back memories
(which we can hardly imagine) of being behind barbed wire in ghettos or prisons, or of being tied down
while abused or tortured. Vigorous encouragement to do rehab exercises may make a survivor re-live
Interventions: Restraints and locked doors should be a last resort, only used when no companion can be
hired and there is real danger of harm to the person or to others. Caregivers should move and speak
softly and show kindness and patience. Respect gender differences and the need for privacy and modesty.
Knock before entering patient rooms, and explain and ask permission before touching clients, especially
when helping to dress/undress and bathe. Use more gentleness than less.
Darkness and night hours.
Reason: Frightening things happened in the dark. Concentration camp prisoners or those in hiding often
had reason to feel terror in the dark just as a child may be scared in the dark – and many were young then.
That fear often did not end with liberation.
Interventions: Leaving lights on in survivors’ rooms at night can help to ease fears of what might happen
in darkness. For some, a small nightlight will help; for others, the room may need to be as light as during
daytime. When checking on sleeping survivors, avoid shining flashlights directly into the face. Music
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playing softly may bring comfort as the time for sleep approaches.
Fire alarms, strobe lights, sirens and whistles.
Reason: Searchlights illuminated camps at night and were used to hunt people hiding. People were
abruptly woken from sleep by flashlights in the middle of the night. Sirens and whistles were often used in
round-ups and deportations (‘Aktions’) and can be frightening now.
Interventions: Avoid intrusive flashlights when making rounds at night. If possible prepare residents
before fire drills.
Dogs used by Police and for Customs Inspection.
Dogs can arouse extreme fears for some while they may bring pleasure to others. Learn people’s history
of reactions to dogs before introducing pet visits in residential care.
Upsetting Smells and Being Unclean.
Reason: In crowded ghettos, thousands of people had to exist in cramped, inadequate conditions. When
the ghettos were cleared and people sent to the camps, they were forced into train boxcars, to stand often
up to 5 days with no food or drink, toilets or fresh air. So now smells of feces or urine can be disturbing. In
the camps, prisoners had to use primitive toilets without toilet paper or privacy, coping with diarrhea and
sickness. Bleach and harsh chemicals were used in camp blocks and “hospitals”.
Today, being unable to care for oneself and having to ask for help - and having to wait - when unclean
adds to feeling not being in control and may trigger horrible memories. Certain smells, even antiseptics or
cleaning fluids that people associate with hospitals, can be upsetting. A barbeque, which may be
enjoyable for many, can bring memories of human bodies burning.
Distressing sounds: cries and screaming.
Reason: Hearing someone cry or scream in a hospital or nursing home may arouse memories or fears of
emotional or physical pain in places of persecution. Announcements over loudspeakers and instructions
on staff radios can cause feelings of loss of control. Some accents and foreign languages can bring back
upsetting memories and cause anxiety.
Interventions: Staff should speak quietly and wear soft-soled shoes that don’t sound like the click of
boots. Prevent keys or tools jangling when walking – and explain this to maintenance and security.
Phones and call buttons should be answered promptly. Switch off loudspeakers in a survivor’s room if
Waiting in lines and crowded conditions; being counted off and directed.
Reason: In the ghettos and camps, people had to wait for hours for food, water or to use the toilet.
Inmates were often awakened at night to parade for hours in all weathers, to be counted or for punishment
or to watch other prisoners being executed.
“Selections” were frequent in concentration camps and people were ordered: “Go to the right!” or “To the
left!” That meant either being taken directly to the gas chambers to be killed, or kept on to work...
Survivors are especially vulnerable to feeling powerless in a crowd or a dark or confined space. Being
stuck in an elevator in a power failure may be especially disturbing.
Intervention: If you need to count the people present do it unobtrusively and without pointing. Avoid lines
of residents waiting for meals, medicines or bathing.
Food: Hiding or hoarding food; eating too fast.
Reason: In wartime and in prison camps, food was scarce (as it was for many who lived through the
Great Depression). Some tried to ration food not knowing what the future would bring. Some stole food to
bring it to those in hiding or too weak to stand in line. Extremely hungry people often ate food very quickly.
Now, despite reassurances that meals will be served again tomorrow, survivors may hide or hoard food.
They are trying to provide for their own needs, unable to trust staff to care for them.
Intervention: Although health and sanitary conditions are essential, try to permit survivors to take food
like canned food or drinks that won’t spoil back to their rooms. Remove stale food from a survivor’s room
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out of sight. It may help to show a survivor that simple snacks are available when they need them.
Separation after family visits; staff changes and new routines.
Reason: Many survivors of extreme trauma were forcibly separated from friends, parents, children,
siblings, spouses and other relatives, who they never saw again. They can feel a terrible fear of
abandonment. Some survivors may be unable to tolerate being alone.
Interventions: Be flexible about visiting hours. Explain patiently before changes in routine schedules.
Washing: Use of the shower, taking a bath.
Reason: In the death camps hundreds of thousands of people were sent to “the showers”. They had
to strip and were forced in large numbers into what looked like shower rooms. The doors were sealed
and poison gas, not water, came out of the spigots. They died horribly. Those who survived were
often sent to showers without knowing if it would be water or poison gas…
Among other cruel ‘research’, some prisoners were put in freezing water to estimate how long downed
pilots might survive in the sea. Others were placed in harsh chemicals to see the effects.
A fear or avoidance of showers now rarely means a simple fear of water or of being clean.
Interventions: Avoid casually speaking about the shower. Instead, ask how the survivor washed at
home. Some prefer to take baths or to use a hand showerhead they can manipulate and control instead of
a regular fixed showerhead. If possible offer the same facilities. Show survivors they have choices and
always explain carefully in different words. Staff can wet an arm to show the water that comes out safely.
Simple wall decorations like flowers may make an institutional shower or bathroom less threatening and
help a fearful survivor feel more comfortable. Change the name on the door. Consider the choice of
clothes – dressing someone in a shirt with buttons may be easier than a tee shirt that has to go over the
Reason: Nazi round-ups were often deliberately held on Jewish holy days, and these were the last time
many saw family members. Now these dates are remembered as the “Yahrzeit”, the anniversaries of their
deaths, and the Jewish tradition is to have a memorial candle alight for 25 hours. The “Yizkor” memorial
service on major Jewish holidays (Yom Kippur, Shemini Atzeret, Pesach & Shavuot) and on Yom HaShoah
the Holocaust Memorial Day, will often bring painful reminders of these losses. If the survivor cannot
attend services, and in institutions where lighting candles are not permitted, being unable to mark these
days can add further sadness to feelings of powerlessness.
Intervention: Facility chaplains may be able to provide electric candles as a substitute.
Current events and political turmoil.
Reason: Violent incidents, war and terrorism here and in Israel remind survivors what they lived through.
TV images and reports of anti-Semitism may be disturbing.
Note: Do be prepared for odd reactions – despite efforts to prepare or protect survivors from stress,
individual responses may be quite unpredictable, and for some, one particular stimulus may not be a
problem. For others, an unanticipated event may cause extraordinary difficulties. Unusual reactions now
may be due to painful memories being re-lived in the present. Survivors may not be aware of causes, and
may not be able to communicate the reason for their acute fear.
Your sensitive response may be critical in how problems are assessed and handled especially if the
particular source of the distress remains unknown. Demonstrating understanding will also help others
concerned by distressing behavior.
Adapted from “Painful Memories: Understanding the Special Needs of Aging Holocaust Survivors”;
Menorah Park Center for the Aging, Cleveland, Ohio.
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Behaviors In the Elderly Characteristic of Earlier Trauma
Stress reactions may be ‘triggered’ when some action causes a person to re-live past traumatic events.
Other people present may have no idea that this is happening, or why.
Some survivors of trauma avoid disclosing their history. Particularly if they are confused or have some
dementia, they may be at risk from excessive stress without even being aware of the causes.
Older people may have diminished coping abilities so further losses, such as the death of a child or a
spouse or close friend, can truly be more than they can bear. Fear of sickness and deterioration in health
also bring added stress.
Older people often live within a small circle of family or friends. Survivors of tragic events that killed family
or friends may have been managing with limited support for years, and they may now be isolated. They
can feel that other people, unless they have had a similar history, cannot understand, or won’t care.
In health clinics, dental offices, assisted living facilities, nursing homes and hospitals, staff may not know
enough of a patient’s history to be aware of their past suffering or present vulnerability.
Identifying & Assessing Changes in Behavior:
Significant changes in behavior of an elderly person observed over a short period could indicate that
traumatic memories have been reactivated. Signs to look for include:
Less able to trust and co-operate; may be more suspicious & may struggle to keep control.
Mood changes: possibly sudden, fluctuating and less predictable; increased anxiety, fearful,
easily startled, irritable; dissatisfied, angry, aggressive, sad, depressed and withdrawn, numb.
Little insight into own condition or of changes in own abilities or of surrounding situation.
Unreasonable hopes and goals.
Increased difficulty communicating. Can revert to first language and lose ability in English.
New or increased physical complaints. It may be easier to seek medical help than to admit intense
Sleep difficulties: changes in sleep patterns, insomnia, and nightmares.
Memory disturbances: flashbacks, distractibility, difficulty concentrating or completing tasks.
May respond as if actually re-living the time of acute trauma and may not be reachable.
Hyper-arousal and vigilance (as if re-experiencing an actual emergency).
May store foods as if preparing for emergency.
Symptoms may change in type and severity.
Assess for cultural factors and communication difficulties with staff such as language that might
otherwise lead to misunderstanding. In institutions, survivors may have specific reactions to the
accent, language, race and gender of some staff providing care, and may be comfortable with others.
Check for physiological causes; changes in hearing/vision, effects of medications, urine infections...
Medical Settings: Survivors may present unusually (some more frequently, others reluctantly).
Ask about history with care; since earlier generations were murdered, survivors may react strongly to
routine questions about their parents’ medical history. Consider effects of extreme exertion and stress
when young, and injury and unprotected exposure to toxic materials during slave labor.
Consider the consequences of T.B., osteoporosis and increased risk of bone fractures.
Evaluate risk of Late-Onset Depression, P.T.S.D. and adverse reactions to anesthesia and
medications for pain control.
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Working with Past Trauma: Clinical Interventions
Listen carefully and with real empathy. Your willingness to hear may be the most useful support you can
offer. Show you are involved, and keep an active therapeutic stance. Offer encouragement: “I’m glad
that I have the opportunity to hear your story.”
Review the survivor’s life during peaceful times before the trauma so the survivor can recall good
memories that may be comforting. The work should not be limited to the trauma and should give a
sense of attending to the whole person.
Convey respect and consider carefully relaxing the usual professional distance. Go slowly, and support the
survivor not to rush. Avoid asking questions simply out of your curiosity – See reference section for
Give the survivor as much control as possible. Start where the client is; invite survivor to decide on the
goals. Have realistic expectations.
Help survivor plan for difficult reactions after re-telling the story and offer suitable resources.
Don’t judge the person and the impossible situation. Don’t question selective (protective) memories, the
amount of disclosure or how the survivor chooses to share the story now. Do not challenge defenses;
numbing was adaptive then and may have helped the survivor cope.
Don’t ask, “How did you survive?” This can bring up regrets, shame and guilt; there is no simple answer.
If the person speaks of feeling guilt and self-punishment over having survived, ask how the victims
who died would want him/her to live and to feel now.
Avoid saying “I know what you mean”, because we, who were not there, cannot know.
Anger can be appropriate. Accept and validate the survivor’s anger at the persecutors, at G-d, at those
who failed to act, and the inadequate responses following liberation and eventual arrival in safety.
Listen for, and focus on, the achievements, strengths, and coping skills. Help the survivor understand that
having survived means having surmounted being a victim, and building a new life showed adaptability,
if not victory. Ask how the traumatic experiences influenced life and later choices. Help find meaning
in being alive, able to make choices now, and in continuing to live.
Identify what the survivor has learned. Help find moral lessons to pass on to family and the next
generation. Assist, if interested, in finding opportunities to share the experiences and teach for the
Ask about physical complaints and use of medical care. Some trauma survivors avoid disclosing medical
concerns to doctors. Emotional pain and psychological difficulties can also present as medical needs.
Seasonal stresses: Difficult reactions may occur around anniversaries of significant losses or other
events. How does political crisis and violence effect the survivor now? Are religious holy days
especially difficult times or are they comforting? Anticipating stresses in advance may help the survivor
plan and prepare, and so feel more in control.
Expect the unexpected – for every cautious effort to prepare or protect survivors from damaging stress,
responses may be quite unpredictable, and the particular stimulus anticipated may not be a problem.
Be honest; avoid being over-protective or promising too much. The damage cannot be undone, although
your respect helps. Many survivors appreciate your acting as a witness to their story.
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This work is demanding. Monitor your own reactions and take care of your feelings and
needs. Seek good support and supervision from colleagues.
Issues for 2nd Generation & other relatives feeling responsible to provide care.
Children of survivors may feel duty to protect parents - less practical as aging proceeds.
They can feel resentment due to the burden; frustration if their parent can no longer
live independently; exhaustion if they have been providing care with limited support;
anger at professionals who cannot be good enough, and guilt over such feelings.
Feelings evoked in professional staff working with aging trauma survivors.
The intersection of our personal and professional responses.
Vicarious stress from working with traumatized people.
Survivors of the Holocaust are now well over 70 years. They are a diverse population. Many were then
young children or adolescents. Almost all survived many extreme situations:
In ghettos, prison, forced and slave labor, death camps and death marches
Hiding alone or with others
Passing as non-Jews with false identity papers
Managing on the run, existing in the forests, or with partisans
Considerable data exists about the experiences of survivors
The special effects on the very young
Their recovery and ability to adapt and grow,
The significant achievements of many since liberation,
And their vulnerabilities in later life and need for sensitive responses.
We are all alike in deserving to have our dignity and individual needs cared for by well-trained and
culturally sensitive staff.
This sensitivity is equally appropriate for any - and all - victim groups:
Non-Jewish survivors of Nazi persecution including Jehovah’s Witnesses, the Roma/Sinti/Gypsy
peoples, members of the Resistance and those caught helping Jews.
More recent immigrants from the Former Soviet Union; some were in prison camps in Siberia;
many suffered extended deprivation
Those persecuted due to homosexuality, or because of their political affiliation
War veterans with combat experience and prisoners of war
Torture victims, and those who suffered in other conflicts and government-inspired persecution
Survivors of, and witnesses to, other trauma:
Child abuse/molestation/domestic and personal violence
Tragedies involving mass casualties
Victims of terror or war and illegal trafficking
Holocaust Community Services 8 Chicago/3.2009