The boundaries of socioeconomic class, religion, gender, nationality, culture, and age are broken down by traumatic events. Although many older adults have experienced trauma, one of the most vivid examples is the Holocaust. Because of the impact this major life event has had on their lives, its survivors may have a unique aging experience. Today, these survivors are at the stage of their lives when many are residents of long-term care (LTC) facilities or are making decisions about institutionalization. The phenomenon of interest in this study was Holocaust survivor residents’ perceptions of a life lived.
Current evidence supports that historical events, such as wars and natural disasters, have a powerful and often enduring impact on the ways in which individuals respond to and cope with the cumulative life challenges they experience. A relevant question, then, is: What are the long-term consequences of such traumatic events? In the research conducted on this topic, the primary focus has been on mental health outcomes. For example, posttraumatic stress disorder (PTSD) has demonstrated long-lasting effects (American Psychiatric Association, 2000; Graziano, 2004; Labinsky, Blair, & Yehuda, 2006; Stesssman et al., 2008).
Holocaust survivors form a group of older adults who, as young people, experienced extreme catastrophic trauma of a physical and mental nature more than half a century ago. In the postwar years, this group was extensively investigated. The majority of research focused on the psychological consequences of the Holocaust experience. Recent studies continue on this same path. Clarke et al. (2004) demonstrated that depressed Holocaust survivors were 52% more likely to have suicidal thoughts compared with depressed non-Holocaust older adults. Later work by this same research team (Clarke et al., 2006) reported that survivors who were in concentration camps had higher rates of suicidal ideation compared with those who survived other Holocaust adversities.
Lamet, Szuchman, Perkel, and Walsh (2009) studied retraumatization and the relationship between specific risk factors, resilience, and psychological stress. They found that Holocaust survivors experienced more posttraumatic stress symptoms during the war on terrorism in the United States than did a comparison group. In contrast, Shrira and Shmotkin (2008) examined the effects of positive and negative autobiographical aspects in later life as a function of the Holocaust experience and age. They reported that even after such trauma and with decline associated with aging, the past can keep life pleasant as demonstrated by a stronger association between past happiness and current life satisfaction, as compared to past suffering.
Other dimensions of survivors’ lives have also been studied. van der Hal-Van Raalte, Van Ijzendoorn, and Bakermans-Kranenburg (2007) found that the quality of postwar child care arrangements predicted lack of well-being in old age. Cortisol levels in aging Holocaust survivors were studied by Yehuda, Morris, Labinsky, Zemelman, and Schmeidler (2007), who concluded that cortisol levels were affected by change in PTSD status (remitted, developed, did not change) and age. McKie (2004) wrote of the ethical themes that emerged from a number of literary texts written by Holocaust survivors. Themes of rationality, duty, witness, and virtue were identified and implications for nursing practice explored. Using the same theme of ethics, Benedict and Georges (2006) examined the role of nurses and the sterilization experiments of Auschwitz, and Brush (2004) looked at nursing practice within the context of Theresienstadt, another concentration camp.
These survivors are now at the stage of life when they increasingly require health care services, which may involve admission to a LTC facility. In general, the experiences of aging among Holocaust survivor residents have received limited attention from researchers, administrators, and practitioners; however, there are a few exceptions. Letzter-Pouw and Werner (2003) reported that Holocaust survivors did not differ in their willingness to entering nursing homes compared with those who did not experience this traumatic event. David’s (2002) work discussed two support groups established within a LTC facility: one for older survivors and one for their children. One identified outcome was that the meetings provided reassurance of the continuity of one’s life.
Purpose and Method
The purpose of this study was to answer the question: What are Holocaust survivor residents’ perceptions of a life lived? A qualitative ethnography method was used. Characterized by inductive, empirical exploration, ethnography is a qualitative approach used to understand the people of a cultural system and to discover meaning as perceived by them. According to Morse and Field (1995), “ethnography is a means of gaining access to the health beliefs and practices of a culture and allows the observer to view phenomena in the context in which they occur” (p. 26).
Ethnography is derived philosophically from symbolic interactionism, which stems from the work of Cooley (1902), Dewey (1930), Spradley (1979), and others. The social interactionist places primary importance on the social meanings people attach to the world around them. Blumer (1969) stated that symbolic interactionism rests on three basic premises: (a) that people act toward things, including other people, on the basis of the meanings these things have for them; (b) that meanings are social products that arise during interactions—people learn how to see the world from the perspectives of other people; and (c) individuals attach meaning to situations, others, things, and themselves through a process of interpretation.
Prior to seeking participants, ethical approval was obtained from the university’s ethics committee. This was the only documentation required by the facilities from which participants were recruited. Participants were recruited through several strategies. Information letters were left on the units, information sessions were scheduled, and resident council meetings were attended. Eleven Holocaust survivor residents from three LTC institutions participated. Only one facility was structured to promote Jewish culture and traditions. Informed consent was obtained and a mental status examination conducted prior to the start of data collection. All residents had moved into the facility within the past 18 months.
Data Collection and Analysis
Data collection consisted of participant observations, semi-structured interviews, and personal documentation. Although the overall intent of the researchers was to have conversations with the residents, semi-structured questions provided consistency in data collection. Spradley (1979) described such interviews as “friendly conversations into which the researcher slowly introduces new elements to assist informants to respond as informants” (p. 58). A researcher (S.P.H. or C.L.L) spent 6 weeks in the setting as an active participant. Each participant had two individual interviews, and field notes were maintained.
Data collection and analysis occurred concurrently. Interviews were audio recorded and transcribed. Analysis involved the frequent replaying of each recording and rereading the transcripts and sets of field notes. Through reflection on the data, initial coding categories emerged into themes. The themes came from the language of the data and were verified with participants.
Although the Holocaust was a personally and uniquely defined experience, five themes emerged from data analysis: Hope and Prayer: Never Again, Sovereignty, Proud of My Old Age, Walking with Others, and Telling Our Stories.
Hope and Prayer: Never Again
Never again, never forget, never repeated—these were phrases expressed by every participant, and never just once, but on average, three or four times during the interviews. The wording was always the same. They expressed hope regarding one central theme: that the Holocaust and its atrocities would never be forgotten by present and future generations. One resident said, “They came and told us that the war is over, finished. We could go home, but we had no homes to go to. Everybody was dead. No one should have to go through what we went through.” This was echoed by another participant: “We worked in the fields but got no food. If we tried to take a few potatoes from the ground, you would get shot. This is no life but we wanted to live.” A desire that no one else should experience concentration camps rang out in their words and faces.
The theme of never again carried through into their immediate postwar experiences, stressing that no one should have to face the years that followed liberation from the camps either: “No one wanted us, we were Jews. We could not get jobs, any work often; and we were sick. You get better but you never really recover.” This was echoed in the words of another participant: “I was office secretary, the second one. Two hours a day for some bread. We were in such poverty. I worked hard, my children have it better now.”
Many participants described the fact that they had no homes or families to return to; regret in their voices was obvious. Regret rang in their stories of families being torn apart:
They came for my father and grandfather, then all the men were taken…they never came home. Our families were smaller. Then they came for the children, in a big truck, all the children, even the babies in their mother’s arms. Some would not give up their babies and went into the trucks with them. No baby should lose its mother. No family should be torn apart like that. It’s wrong.
To deal with the loss, some participants spoke about pseudo families being created both in the urban ghetto and in the concentration camp:
It was almost 3 years that I was in that camp, never knowing what became of my own family. Was I going to live? I prayed. One of the older women in the camp was nice to me; she cuddled me, and talked me, like my own mother.
In the emergence of new families was the thread of continuity of hope for the future. Yet, the desired future was not a repeat of the past: “We had death and hope in the camps, but I don’t know where hope came from, perhaps just from each other, that we were alive on that day.”
Although participants identified their hope for the future, they recognized the uncertainty interwoven in their hope and the need for collective efforts to achieve the same. As one resident said, “Do we ever learn from our mistakes?” While another said, “It’s world peace we need, not local peace.” They felt that the past was a teacher, but that students did not always learn its lessons.
Sovereignty describes a sense of independence, of self-determination in one’s life, of the ability to make choices. Participants described their independence as being a contributing factor to both their happiness and their acceptance of living within the LTC facility. They spoke about it in a manner that associated independence with a sense of freedom. They cited examples such as “to get to the dining room” and “to feed myself.” Another participant said, “I can get to the bathroom, takes a bit of time…but I don’t need a diaper like some of them do here.” While another described himself as a “hell raiser, I do what I like and sometimes the staff don’t like me much.” On the other hand, the participants also acknowledged that it was often a reduction in their independence that contributed to their decision to move into the facility.
For these participants, independence was closely associated with their mental capacity. They expressed worry about what would happen if their cognitive status changed, as it might mean they would no longer have the ability to control their thoughts and perhaps they would forget the atrocities of their youth. One resident said, “I do not want to forget,” while another voiced, “What happens to our fathers and mothers if [we] lose our memories of it [the Holocaust]?”
At the same time, most participants expressed regret about living on the same units as those who were experiencing dementia symptoms. As one said, “They should not mix us up [dementia and cognitively intact residents on the same unit]. I don’t want to end up like that.” One participant recalled an incident from the camp: “There was an old lady—at least she was old to me—and she just went crazy. I see the same thing here.” They did not want to view this condition as their own future.
For these same participants, sometimes sovereignty was achieved in interesting ways. Once they were liberated after the war, stealing to obtain food seemed to be an inevitable choice for many so they could survive. One participant said, “There was no work, and who would hire someone like me—half naked, cold, no place to live. I had to steal, I wanted to live. I knew it would get better.”
Proud of My Old Age
Participants were proud they had survived the Holocaust and lived to their current age, stating: “At my age, I have seen everything,” and “You do not get to be 89 without having seen a few things.” Another described her life after she left the camp:
I went back to my home, but it was not there. We went to Israel first, then here. There was no work there. When we came here, we had no money. You could not take it out of the country with you. We had to depend on my brother’s family. They gave us some plates, only four because there were four of us. When I moved in here, I had two full china services. I earned it by working hard.
Another participant commented about what she had accomplished in coming to Canada:
I started out cleaning the washrooms, then I worked on the floor [industry], and then they made me a supervisor. They said it was because I was a hard worker, and I stayed there till I retired. It was good working but good to retire and live a bit.
Matriarchal and patriarchal roles in their families were one of the perceived rewards of longevity. They expressed joy in witnessing generations of their descendants: “I bounced her [great granddaughter] on my knee” and “My grandchildren are now having children of their own.” They accepted with grace the changes that come with age, although they did not always like them. As one older man said, “What else can you do? After everything that has happened to me, this is just one more experience. Nothing stays the same.” They did recognize that aging had contributed to their need to relocate to the facility, primarily because of reduced mobility.
In addition, participants emphasized the importance of acknowledging the past but of living for the day. They stated that this perspective helped them cope with their history, as well as address the uncertainty of the future. As one said, “Life is a series of corners and one never knows what lies around the next one.”
Walking with Others
Participants identified one reason for their move to the facility: a desire not to be alone, which was strongly influenced by the views of their children. The desire to be busy and to help others was also expressed by participants. They described that being busy helped them control thoughts of their negative past memories: “It keeps my mind from focusing on things I don’t want to think about.” Often, “others” included the families that emerged after the end of the war, when marriages occurred:
As an old lady, my life is fulfilled. I have children and grandchildren. My granddaughter, she visits me here. Her husband is a teacher. In the spring, they had their first child. That makes me a great grandmother again.
Participants reported feeling happy and satisfied with their lives because of the relationships they had with their families. However, not all family experiences were positive:
My husband is always sick. He came out of the camps sick. We could not have children and I think that is perhaps why. I had to look after us, I got a job when we came to Canada. He could not hold a job.
Interestingly, participants expressed concern that they did not have timely access to a physician when they needed one. When they made a request to a staff member, they did not always trust it would be acted on, exemplified by phrases such as “Would they give them a phone call?” and “You ask the staff but sometimes nothing happens when you need to see someone [doctor].” Another participant said, “My daughter takes me to the specialist for my eyes. She always picks me up and gets me back.”
Telling Our Stories
Participants spoke about the value for oneself in the sharing of their stories with others. The telling of stories provided hope that the atrocities of the Holocaust would be remembered forever and would never happen again. They wished their caregivers knew what they had gone through and how this might influence their daily life. As one older man recounted, “I used to go to the schools and talk to the children, they liked me coming in. I told them what it was like for me and they listened. They liked to ask questions.”
Several participants commented on the small number of survivors living in the LTC facility and thus the lack of people knowledgeable of their past and their current needs: “There aren’t many here who know our stories. Most of them here are not Jewish.”
Not all participants wanted to tell their stories. As one older woman said, “It is hard still to tell about the camps. It was so bad. You don’t want to live with the memories. If I don’t want to live with them, why should someone else have to?” Each participant seemed to make a personal decision about whether to tell his or her stories. Sometimes the presence of grandchildren encouraged story telling, but not always. One participant said, “Should you tell your grandchildren? They hear some stories in school but then they asked me. I did not know what to do. It is better I tell them, so they know the truth.”
Discussion and Implications for Nursing Practice
What ties the themes together is resilience—the ability to apparently recover from the extremes of trauma and related stress. The concept is important to gerontological nurses as it facilitates the positive adjustment to and recovery from lifestyle changes, relocation, and related health challenges. The participants’ pragmatic approach to the need to relocate is typical of Helmreich’s (1992) description of resilient individuals. He contended that one of the salient qualities that helped survivors adapt to their new life after the war was their assimilation of knowledge about survival. The older residents in this study demonstrated a high level of adaptation to this latest relocation. Their level of adaptation is consistent with what Lomranz (2005) found in his review of the research findings of other Holocaust survivors.
Resilience is also manifested in the hope felt by these older residents. To hope is to wish for something with the expectation that the wish is fulfilled. Their perspectives are similar to the depictions of hope conveyed by nurse researchers Morse and Penrod (1999) and Walsh (2002). Nurses need to foster this hope. If appropriate, they may do so by expressing their own wishes for peace or stability in the world. For residents whose hope is linked to their faith, another strategy might be to encourage the resident to converse with the facility’s rabbi or, if possible, to continue attending their faith services. If this is not possible, arrangements can often be made with the local synagogue for a rabbi to visit.
Gerontological nurses also need to promote the involvement of older residents in the LTC facility activities. Brandler (2000) wrote about how being busy with activities helped survivors minimize negative thinking about the past. Harel (1995) acknowledged the benefits that survivors gained by being around other people as leading to increased comfort, activity, and socialization, as well as less time spent dwelling on negative memories. These findings of the current study confirm the earlier work of Lee (1988). She found that successful adaptation related to current engagement in creative activities (e.g., music, poetry writing) and their involvement in similar activities from a young age (pre-Holocaust) promoted inner strength for survivors and may have helped them distance themselves from some of the traumatic events of the Holocaust.
An important role for LTC staff is to provide a therapeutic environment for those who live there. Actively listening to residents about their Holocaust experiences is an effective strategy to promote residents’ feelings of comfort within their new environment. Participants in this study wanted nurses to know their stories. Bar-Tur and Levy-Shiff (1994) found that the telling of stories and bearing witness was a coping mechanism that enabled survivors to deal with the past, as well as maintain mental health in old age. The relocation to a LTC facility was viewed as a decision over which they had some control but not always choice. Their stories contained details of the planning for this move, which was often influenced by their children. They made the decision because of their need to be with people, as they feared being alone would hinder their ability to block painful memories.
One nursing need unique to this population relates to the study participants’ concerns about timely access to physicians. This apprehension may be related Schwartz’s finding (as cited in Geiger & Davidhizar, 2004) that concern for immediate access to physicians was perhaps a result of experiences during the Holocaust. Illness was often associated with death and resulted from neglect or no access to health care. Staff need to be aware of this as it may influence communication among facility staff or the method by which a resident’s physician is contacted.
A similar perspective was offered by Behnia (2004), who commented on the importance of trust being present for a therapeutic relationship to develop between a survivor and a health care professional. He noted that information about the health care professional that is shared can help the older adult form an opinion about the professional and facilitate the development of trust. The implication of this relates to the nurse sharing personal information with the older Holocaust survivor resident, if appropriate.
Participants wanted their Holocaust experiences understood by staff. Bernick, Grinberg, Holynaty, and Rodgers (2001) acknowledged the importance of the health care team being educated about the Holocaust and its impact on survivors. Information specific to the needs of Holocaust survivor residents might be provided through educational inservice sessions. If available, classroom instruction should be supplemented with “teachable moments”—learning interactions that occur between unit staff or between an educator and a staff member.
While this study deepens the understanding of older Holocaust survivor residents, it also raises questions. Do certain actions within LTC facilities (e.g., secure or locked units) contribute to the recall of memories? How does the progression of dementia, if it occurs, interrelate with the Holocaust experience? Further research in this area can contribute to the quality of life of older Holocaust survivor residents.