SHIFTING PARADIGMS FOR CLINICAL PRACTICE WITH VULNERABLE POPULATIONS
The new millennium is predicted to be a time of political, economic, cultural, and ideologic changes that will dramatically affect how health and social services are defined.1 Given the far-reaching social and economic changes that affect and are predicted to affect the aging population, there needs to be a shift in geriatric practice to models that help maintain the independence and well-being of older adults. An understanding and implementation of a resilience philosophy—one that turns the attention of health and human service providers to people's inner strength and enables people to successfully overcome the psychologic impact of adverse events—can revolutionize clinical practice.2 Resilience-enhancing interventions can build on survival and coping skills that are already being used by older adults to cope with difficult life situations.3
Although adverse events can threaten people's psychologic and social stability, the level of trauma and the course of long-term recovery from adverse events vary by individual: some may suffer few lasting effects, whereas others may experience posttraumatic stress disorder. Nonetheless, most people show remarkable “self-righting tendencies”4(p127) or resilience. A growing body of literature5,6 suggests that the search for meaning following stressful events is a universal and essential task that either may occur naturally or may be brought forth through clinical intervention.7
Survivorship is a complex phenomenon involving the ability to survive and recover from severe adverse events or traumas. During and after such critical events, individuals, families, and communities use both their innate and learned abilities (ie, traits) to engage in actions (ie, follow adaptive coping strategies) that allow them to respond to the adverse event, deal with feelings of distress, and then begin to heal. Responding to an adverse event can involve
- finding some sense of safety in recognized routines;
- obtaining information and resources that are useful in a particular situation;
- resolving stressors;
- reestablishing a sense of control or self-mastery, or the sense that there are choices to be made, no matter how small;
- seeking and providing mutually supportive relationships;
- identifying meaning in the event that may be related to spirituality;
- maintaining positive emotions and creativity; and
- gaining an appreciation of newfound strengths or an affirmation of life.
During the Nazi Holocaust, survivorship also required combating negative environmental (ie, political and sociocultural) events.
EFFECTS OF THE HOLOCAUST ON SURVIVORS
When a terrible adverse event such as the Holocaust occurs, people find that their world no longer makes sense and their fundamental assumptions about the meaning of life are challenged.7 If an event is perceived as meaningless, life is experienced as being without purpose or function, intention, and significance. There is no design for living, order or an organized system for making choices, or a sense of direction. In an attempt to cope with such negative circumstances, people engage in meaning making or “forming and reforming of intention and significance.”8(p23)
A traumatic event of the magnitude of the Holocaust, involving sustained stress over a long period, may upset an individual's basic suppositions to the extent that the world is no longer comprehensible to him or her.9 Disaster of such magnitude disrupts the social fabric, placing extreme demands on individuals, families, and communities and often exceeding personal and community resources.10,11 Yet, many survivors of the Holocaust have somehow demonstrated resilience, creating new lives out of the ashes of the past.
Strumpfer,12 for example, argued that resilience can be activated by external life contexts, circumstances, and opportunities. The process of “resiling,” or activating resilience, can be viewed as beginning when someone perceives a challenge or a threat that motivates him or her to set and carry out new goals. In this sense, the person does not have ongoing resilience, but resilience is triggered by demanding situations—exceptionally challenging experiences, developmental transitions, individual adversity, collective adversity, organizational change, and large-scale sociopolitical change. All of these were characteristic of the Holocaust. Thus, this study assumes that resilience is an emergent quality that is set in motion when a person is under stress. As a study participant recalled, “When you survive Auschwitz, you have a choice. You choose life, or you throw yourself under electric wires.”
Most Holocaust survivors have now reached old age, a time when many people review their lives, attempt to resolve old conflicts, and find new meaning in life events. How have Holocaust survivors who have experienced unprecedented separation and loss met the challenging transitions of their final stage of life?13 Have they relived the trauma of the Holocaust as they have experienced the aging process? Have they exhibited resilience—the capacity to overcome the exposure to severe risk that they have experienced?10
Resilience: An element of survivorship
This article discusses risk and resilience theory as a key element of survivorship. Critical events experienced by survivors illustrate their resilience across the life span. Understanding subjective well-being is particularly pertinent with regard to this vulnerable population14 as health and social service providers explore current care strategies for them and others who have faced or are facing adversity.15
Much has been written about the effects of the Nazi Holocaust on its survivors, and there are differing views about its possible long-term effects. Theorists have reported that posttraumatic stress disorder in Holocaust survivors can last a lifetime.16 Older Holocaust survivors have been robbed of the normal life cycle of aging, are sick more often than the elderly who did not experience this trauma, and experience nightmares flooded with images of their Holocaust experience. An unknown number of survivors are said to experience old age with a sense of abandonment, isolation, or loneliness more pronounced than those of other older adults in their communities.17
Although reports of severe and debilitating disorders, such as chronic anxiety and depression, must never be taken lightly, there is also clinical and empiric evidences that many survivors actually are “resilient, creating families, developing careers, and leading creative and productive lives despite the ordeal.”18(p126) However, there is insufficient research about what contributes to survivors' “posttraumatic healing and mastery of intrapsychic injuries,” including their ability to lead successful lives and contribute to society in the aftermath of trauma.19(p182) This article describes some of the factors that have allowed survivors to deal with severe stress, sense of loss, vulnerability, and grief, successfully make life transitions, and deal with environmental demands.
This preliminary discussion of the John Templeton Foundation project builds on earlier research on resilience that documented stories of hope and determination as well as captured one of the most impressive human qualities—the ability to self-right following grave setbacks and major crises.20 For example, Frankl,21 a Holocaust survivor himself, spoke of his ability to create meaning during his time in a Nazi concentration camp. Another resilience approach was developed by Antonovsky,22 who used the phrase “salutogenesis orientation” to encompass his study of how people naturally use their resources to strive for health.
Earlier risk and resilience research has provided evidence that many survivors have demonstrated resilience, making new meaning of their lives in the aftermath of the Holocaust, creating families, developing careers, and leading creative and productive lives.18 In Against All Odds: Holocaust Survivors and the Successful Lives They Made in America, Helmreich23 examined the lives of a random sample of survivors, finding that they managed to reconstruct their lives after the Holocaust. Schiff and Cohler24 found that Holocaust survivors continued to have strong emotions about their experiences 50 years after having survived concentration camps. Surviving the Holocaust remained a pivotal event in their lives. Yet, a subanalysis of the transcripts of interviews of 20 concentration camp survivors revealed that their survival was complex and that survivors appeared to “put themselves together” and organize their thoughts about survival through “a sense of meaning in the present.”24(p119) Themes that emerged from these interviews included taking up purpose, exemplifying a miracle, and experiencing a moment of meaning.
A study by Greene20 underscored that resilience was evident and effective in communities that were sustained even during the extreme circumstances of the Holocaust. Although some survivors reported feelings of anger and continuing disbelief in their old age, they recounted that during their time in concentration camps, they maintained personal bonds, made choices, and controlled their lives through their own special and sometimes secretive means. They set up governmental structures and schools, performed concerts, and even wrote poetry. Analysis of Greene's interviews showed positive themes such as survivors making a conscious decision to go on living, celebrate life, and think positively about themselves.20 We hoped to learn if these themes would be repeated here.
Resilience can be viewed as an ecologic or multisystemic life course phenomenon20 that involves one's ability to maintain coherence or continuity in one's life story.6 It refers to people's individual and collective behaviors, circumstances, and achievements that allow them to overcome adversity, or in the case of the Holocaust, the actions a person might have taken to survive and find meaning such as caring for another, joining an underground group, or undertaking acts of sabotage such as blowing up railroad tracks.25 For example, a study participant recalled,
I was very strong in my belief that we will survive. I knew that I had to survive. I had a mission to survive. I did everything to do it. Whatever was necessary. In the Partisans, we killed. We blew up bridges.
Resilience encompasses the life course26—the timing of life events—and the social structures and historical events a person experiences. With regard to the Holocaust, behaviors during World War II and subsequent adaptations should be examined. Thus, to understand resilience, researchers must explore the individual's life transitions, family configurations, and changing social conditions.27 Comments by a study participant about World War II and the Jewish people's fight for survival illustrate the historical context: “Wars create children warriors. All of them. You see them today. And more than 60 years ago. When we sacrificed our loved ones, they become warriors.”
Resilience may also be conceptualized as either adaptation to stress or an individual's subjective reaction to life events that require adaptation. Life events are regarded as stressful when they are appraised as so taxing that they pose a threat to life, a frequent occurrence during the Holocaust.28
Although resilience is sometimes thought of as a trait, it needs to be understood primarily as a process that evolves over time.26 Research, therefore, should focus on whether severe stress results in psychologic difficulties and the conditions that build, foster, and mobilize adaptive strategies. It is then possible to examine the factors that contribute to resilience and how people are able to withstand stressful conditions and continue to carry out life transitions or milestones.
Research to date has suggested that resilience is the variation in an individual's response to risk,29 as well as a larger-scale phenomenon dealing with the collective coping of community members.10 Two definitions of resilience have been adopted here:
- Fraser30 used the term “resilience” to describe adaptation to extraordinary circumstances (ie, risks) and achievement of positive and unexpected outcomes in the face of adversity. This definition is used here as the theoretical base for exploring cumulative risk as well as protective and resiliency factors that contribute to survivorship.
- Masten31 suggested that resilience be viewed as the ability to maintain competence across the life span. This definition is used here to explore the degree to which survivors retained their competence through life course transitions.
Resilience: Basic terms
From a resilience perspective, 4 basic concepts should be considered in the review of survivor interviews: risk, vulnerability, protective factors, and resilience. Risk is the probability that a person may experience a negative outcome following an adverse event.30 Researchers of the Holocaust have approached the study of risk factors in 1 of 2 ways: (1) by examining specific risk factors or particular antecedents that they have then attempted to link to future outcomes such as a survivor's risk of being imprisoned or killed; or (2) by either studying cumulative risk or trying to understand the additive effects of years of living on the run or in a concentration or labor camp. Cumulative risk is the number of negative life events or experiences in a lifetime and is used to identify a client as high-risk or low-risk. In the case of the Holocaust, a person with fake papers might have been constantly afraid of being found out and thus on the run.
Vulnerability refers to factors that are more likely to increase an at-risk person's negative experience. A vulnerability factor is a characteristic “that makes that person more susceptible to a particular threat to development.”31(p7) In Europe prior to World War II, due to political unrest and the anti-Semitic sociocultural climate, Jewish people were among the vulnerable populations, which also included gays, Romanies, and political dissidents.
Protective factors moderate the effects of risks and enhance adaptation. Such factors interrupt, prevent, or cushion against risk.31 A positive personality, high self-esteem, and family warmth and cohesion before, during, or after the war could serve as protective factors, as could an extrafamilial social environment that provided support such as refugee agencies that resettled survivors.4 Protective factors may also include cultural values and ethnic group support that continued in concentration camps.32
The Templeton project
This article comes under the aegis of a larger study entitled Forgiveness, Resiliency, and Survivorship Among Holocaust Survivors, funded by the John Templeton Foundation, which will culminate in the formulation of a survivorship model to be published elsewhere at a future date. A number of theoretical frameworks consistent with a philosophy of resilience are being used in the Templeton study to describe critical events in Holocaust survivors' lives: Yael Danieli's Family Typology,17 Robert Enright's Forgiveness Inventory,33 Erik Erikson's Healthy Personality,34 and Roberta Greene's resilience-enhancing model.3,10 The study also incorporates Armour's concept of performance meaning making.7,35
We wanted to learn (1) how relatively forgiving participants are, (2) how resilient they say they are (as it relates to being a Holocaust survivor), (3) how successfully they perceive that they have accomplished Erikson's 8 stages of life, (4) how these factors are interrelated, and (5) how survivors' Holocaust experiences affected subsequent life events and prepared them for old age.
The data presented here on the role of resilience in survivorship were derived from the larger Templeton project, which involved interviewing 133 Holocaust survivors in 9 US locations: Austin, Dallas, Houston, Los Angeles, Minneapolis, New York, New Jersey, San Antonio, and Washington, DC. The snowball sample was obtained through word of mouth, posting flyers, and accessing volunteers at Holocaust museums.
Participants volunteered to complete structured interviews conducted during 2- to 2.5-hour face-to-face recorded sessions. The survey protocol consisted of 188 questions addressing demographics and the elements of survivorship.
To arrive at an understanding of Holocaust survivors' resiliency, we selected interview data from the overall survey about family circumstances before and after World War II and the adaptive strategies undertaken during the Holocaust. We wanted to learn (1) which influences before the war such as a warm supportive family environment served as protective factors; (2) which resilient behaviors were used during the war to survive the ongoing trauma; and (3) which milestones survivors met that suggested they remained competent or resilient after the war.
RESILIENCE: GENERAL FINDINGS
The sample of 133 survivors consisted of individuals ranging from 68 to 93 years of age, with a mean age of nearly 81. One-third were men and two-thirds were women. Countries of origin were primarily Poland, Germany, and Hungary. A majority (56%) of those interviewed spent the war in ghettos and concentration camps. Participants also served in partisan groups, worked in labor camps, or went into hiding.
Protective factors before the war
Past research has suggested that the development of resilience is highly correlated with a positive early family environment.4 Our findings also suggest that a positive family climate before the war contributed to resilience. A great majority of participants remembered having a positive foundation in their parents' home. More than 75% reported that their home had a warm and supportive environment, with another 18% stating that their family was close in difficult times. Almost all participants (97%) remembered being well cared for when ill. Moreover, 84% lived in good or very good economic conditions because their parents had been engaged in small businesses. Other family occupations included farming and publishing, as well as rabbinic work and medicine.
Resilient behaviors during the war
During the war, participants engaged in many adaptive/resilient behaviors such as trying to survive in family groups. Survivors' stories often contained information about how they bartered for goods, exchanged favors, bribed guards, and organized underground resistance units, replicating the findings of an earlier study by Greene.20 Several quotes (Table 1) demonstrate participants' resiliency while they endured horrific conditions.20 For example, 64% of participants remembered resolving to live, 50% recalled making friends, 55% turned to others or banded together, 50% found ways to get “extra” food, and 48% cared for others. In addition, close to 40% were aided by “righteous others.” More than one-third remembered fighting for their lives and 20% tricked and sabotaged the guards.
One participant remembered the struggle to obtain food: “We would go out of the ghetto at night and smuggle through a fence. Steal some potatoes and corn from the fields. We improvised for whatever was necessary.” Another bold participant remembered: “And maybe we sabotage some of the soldiers by tricking them into chasing us through the ghetto so that they might be eliminated.”
Resilient behaviors after the war
Resilience is a pattern over time “characterized by good eventual adaptation despite developmental risks, acute stressors, or chronic adversities.”31(p5) Researchers frequently use the criterion of meeting adult developmental milestones as an indication of resilience following childhood or adolescent adversity.36 The data in this study suggest that Holocaust survivors' life patterns after the war were generally positive. For example, most survivors married and had children. Only 6% reported having no children. In addition, survivors continued previously interrupted education, with as many as 35% attending graduate school. Careers established by survivors ranged from business to dairy farming, and some engaged in medical research or teaching.
SUMMARY AND CONCLUSIONS
During the period beginning with Germany's oppression of European Jewry (as well as gays, Seventh-day Adventists, and Romanies) and ending with liberation from the Nazi regime, survivors experienced conditions that constituted an extreme risk to their survival. The threats to survival were continual and unpredictable, and they were intended to satisfy Hitler's “Final Solution”—the extermination of the Jewish people. During the Holocaust, all aspects of survivors' existence were at risk including the availability of basic needs such as food, water, and shelter; safety from injury and disease; and psychologic and spiritual health. Study results demonstrate survivors' ability to face these risks, exhibiting the self-righting nature of human development. In the words of a study participant,
It is a very cruel and difficult part of my life. Sometimes I wonder … when I visited the camp with son, wife, and grandson … and my friend's wife and son. I was amazed—how could anyone escape from that place. Yet, I did escape with sheer craziness! I feel like I am very strong healthwise, mentally. Strong willed in my life. I am capable of thinking even with fear of death. I am not afraid of dying now. I am very strong. I want to die peaceful—I don't want to die tired.
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