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Physical illness in children of Holocaust survivors
Phvsical Illness in Children of Holocaust Survivors J
Shimon Waldfogel,
M.D.
Abstract: During medical or psychiatric hospitalization, Nazi Holocaust survivors may display emotional symptoms that reflect the psychological sequelae incurred by their traumatization. What is often less recognized is the idiosyncratic responses that may be seen in the children of these survivors in response to physical illness and hospitalization. Psychiatrists should be alert to the possible effects of Holocaust-related experiences. Awareness of emotional conflicts, defenses, and strengths in these individuals may enhance the therapeutic alliance as well as treatment planning. The author describes two cases illustrating adaptive and maladaptive manifestations of the Holocaust theme in response to medical illness.
Introduction It is well documented that the psychological impact of the Holocaust can be passed from survivors to their children [l-g]. The interplay of the Holocaust experience and serious medical illness and hospitalization in survivors themselves [9,10], as well as the idiosyncratic response to psychiatric hospitalization in their offspring, have also been described [ll]. Nonetheless, the psychiatric literature rarely profiles the particular stresses of physical illness and medical hospitalization in survivors’ children. “Intergenerationally transmitted’ [5] psychological sequelae of their parents’ Holocaust experiences may significantly influence the response of survivors’ children to their own physical illnesses and hospitalizations. As these individuals are reaching middle age and beyond, with the resultant increase in morbidity, such reactions may be more commonly seen by the physician in the medical setting. The lack of awareness in the psychiatrist of the
From the Department of Psychiatry and Human Behavior, Jefferson Medical College, Philadelphia, Pennsylvania. Address reprint requests to: Shimon Waldfogel, M.D., Department of P~ychiatryLandHuman Behavior, Jefyerson Medical College, 11th and Walnut Streets, Philadelphia, PA 19107. GeneralHospital Psychiatry
13, 267-269, 1991 0 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
relationship of these underlying factors to the expression of symptoms can lead to misdiagnosis and to the omission of potentially beneficial interventions. The following two cases illustrate the incorporation of the Holocaust theme into the psychological responses of survivors’ children to physical illnesses. The Holocaust theme, as these examples show, can be used for adaptive or maladaptive coping patterns in those with physical illnesses.
Case 1 Ms. A, a 42-year-old Jewish, married mother of two children, was seen in psychiatric consultation for severe anxiety during a hospitalization due to a thrombus of the inferior vena cava. Ms. A was initially reluctant to speak with the psychiatrist and was surprised that such a consultation was requested. An evaluation revealed that she was the only child of Holocaust-survivor parents. Upon arrival in the United States at age 6, Ms. A had quickly assumed the role of “parent” to her mother. Her rapid acquisition of English helped foster dependency of her parents upon her. Both parents had died prior to her hospitalization; her father 10 years before, and her mother 5 years before after surviving for several months after a cerebrovascular accident. Ms. A cared for her mother during the illness. The morning after her mother’s death, she reported feeling “I was my mother.” In the 5 years after her mother’s death, she developed symptoms of asthma and diabetes mellitus, both of which were illnesses her mother had. Following surgery to evacuate the thrombus, Ms. A developed a transient delirium and became extremely anxious, hypervigilant, and paranoid. She insisted on having her family stay with her. The delusional content of her delirious thoughts seemed to be related to her parents’ Holocaust experiences. Ms. A felt that she was in a concentration camp similar to the one her mother had experienced. She also ex267 ISSN 0163~8343/91/$3.50
S. Waldfogel
pressed fear of the nurses and doctors, whom she identified as Nazis. Regular reorientation by the staff, acknowledgment and discussion of her fears regarding her medical situation, and empathic clarification regarding the connection of her psychiatric symptoms with her parents’ Holocaust experiences helped greatly to reduce her symptoms of paranoia and anxiety. Her delirium cleared without medication within I2 hours.
Case 2 Mr. B was a 34-year-old, single, Jewish son of Holocaust survivors, who was found to have Hodgkin’s lymphoma soon after his arrival from an Eastern European country to pursue graduate studies in the United States. Mr. B did not inform his parents of his illness, noting “I didn’t want to burden them after what they went through.” During the subsequent radiation treatment, he began to experience weakness, nausea, vomiting, and weight loss. He felt like “the living death,” and said, “I have nothing left, I have lost the feeling of existence,” When his hair began falling out, he referred to the experience as “my Holocaust.” During psychiatric interview, Mr. B recalled his father’s accounts of the concentration camp. He remembered in particular his father’s reactions to his first encounter with death: an increased identification with the suffering and survival of the Jewish people and “a joining with Jewish existence and its tradition of survival.” Mr. B began to employ the same coping mechanism in response to his own “Holocaust” as his father had used in his concentration camp experience. Through this identification, he reported “feeling stronger, and gaining energy and strength.” He sensed a change in his world view; he became more spiritual and experienced a rekindling of the search for his Jewish roots. Mr. B’s father had been in the concentration camps at approximately the same age that Mr. B was struggling with his illness. Though the Holocaust was discussed often in his childhood home, his father’s personal experience in the camps was talked about only upon Mr. B’s request when he was 25 years old. Mr. B’s primary psychological response to a potentially catastrophic illness revolved around his identification with his father as a survivor rather than as a victim. This positive identification gave emotional meaning and strength to his suffering and thus became an adaptive way to cope with his illness.
Discussion The psychiatric literature has had numerous descriptions of the emotional difficulties experienced by children of Holocaust survivors as they undergo 268
the individuation process [l-5]. These children may grow up to be their parents’ “bridge back to life” [4], and often carry the burden of trying to vindicate their parents’ suffering. They also frequently experience conflicts in identification with parents, either as degraded victims or as omnipotent survivors [3,4]. The parents’ pervasive silence about their traumatization may paradoxically intensify Holocaust-related fantasies and positive and negative identifications resulting from these fantasies [4]. The delusional thought content of Ms. A’s delirium was based upon an identification with her parents as Holocaust victims. The intensive care setting was perceived by her to be a concentration camp and its staff as Nazis. The sense of helplessness that accompanies severe illness and hospitalization may symbolically represent incarceration in concentration camps for Holocaust survivors and their children [5,11]. These individuals may therefore have difficulty trusting health care professionals, especially those who are not Jewish [3]. Some extreme cases may benefit by involving a Jewish physician or nurse who can directly address the patients’ concerns. A particular resistance to psychiatric evaluation may be evident out of fear of being labeled “crazy,” which resulted, in the camps, with being promptly sent to the gas chambers 151. Mr. B’s response to his illness, through identification with his father as a survivor, demonstrates the adaptive use of the Holocaust theme. The sense of transcendence in Holocaust survivors’ reactions to concentration camp experiences, as well as the survivors’ use of the concentration camp experience in an adaptive manner, have been described elsewhere [12-141. The utilization of transcendence as an adaptive coping mechanism by the survivors’ children has rarely been described. Cassel [15] noted that “transcendence is probably the most powerful way in which one is restored to wholeness after an injury to personhood. When experienced, transcendence locates the person in a far larger landscape. The sufferer is not isolated by pain but brought closer to a transpersonal source of meaning and to the human community that shares those meanings. “ Problems with separation issues may also be prominent for Holocaust survivors and their children. In the Holocaust, separation often assured never seeing one’s family members again [5]. For some Holocaust victims and their children, hospitalization may be the first extended separation
Illness in Children of Holocaust Survivors
from their home and family, thus reactivating a powerful sense of potential vulnerability. Nevertheless, some individuals like Mr. B may be reluctant to further burden their parents or others with their own emotional needs, fearing that they will add to or reawaken their parents’ or others’ suffering. Separation in the form of hospitalization thus assumes a doubly poignant significance for them; there is increased risk, but also a reluctance to discuss this among the family members, often coupled with a lack of conscious awareness of these factors.
Summary Idiosyncratic psychological reactions incorporating the Holocaust theme may emerge during medical or psychiatric hospitalizations of offspring of Holocaust survivors. Psychiatrists should be alert to the possible manifestation of the intergenerationally transmitted effects of Holocaust-related experiences. Awareness of these individuals’ emotional conflicts, defenses, and strengths in these areas, may facilitate the opportunity to form a therapeutic alliance with them. An understanding of the vulnerability that Holocaust-related trauma creates may help the psychiatrist diagnose and develop treatments that enhance these individuals’ ability to cope with the stress of their illness and hospitalization. The informed psychiatrist can better help patients, their families, and medical treatment teams to understand the manifested response. Drawing upon the offspring’s identification with the parent as a survivor may enhance the patients’ ability to cope with their illness in some cases. When indicated, empathic, reassuring, and yet indepth exploration of these issues with the patient may significantly relieve the symptoms that led to the psychiatric consultation and even improve their cooperation with further necessary medical treatments. Such dynamically informed psychiatric consultation may additionally prepare them for future psychotherapy, if needed, which may enable a greater integration of the Holocaust experience into other aspects of their lives.
The author would like to thank Salman Akthar, M.D., Troy L. Thompson II, M.D., and Paul Root Wolpe, Ph.D., for their helpful comments on the manuscript.
References 1. Barocas HA, Barocas CB: Manifestations of concentration camp effects on the second generation. Am J Psychiatry 130:820-821, 1973 2. Barocas HA, Barocas CB: Separation-individuation conflicts in children of holocaust survivors. J Contemp Psychother 11:6-14, 1980 3. Phillips RE: Impact of Nazi Holocaust on children of survivors. Am J Psychother 32:370-378, 1978 4. Levine HB: Toward a psychoanalytic understanding of children of survivors of the Holocaust. Psychoanal Q 51:70-92, 1982 5. Danieli Y: Treating survivors and children of survivors of the Nazi Holocaust. In Ochberg FM (ed), Post-Traumatic Therapy and Victims of Violence. Psychosocial Stress Series No. 11. New York, Brunner/Mazel, 1988, pp 278-294 6. Link N, Victor B, Binder RL: Psychosis in children of Holocaust survivors: influence of the Holocaust in the choice of themes in their psychosis. J Nerv Ment Dis 175:115-117, 1985 7. Solomon Z, Kotler M, Mikulincer M: Combat-related posttraumatic stress disorder among secondgeneration Holocaust survivors: preliminary findings. Am J Psychiatry 145:865-868, 1988 8. Rosenthal PA, Rosenthal S: Holocaust effect in the third generation: child of another time. Am J Psychother 34:572-580, 1980 9. Baider L, Sarell M: Coping with cancer among Holocaust survivors: an exploratory study. J Hum Stress 10:121-127, 1984 10. Edelstein EL: Reactivation of concentration camp experience as a result of hospitalization. Ser Clin Community Psycho1 Stress Anx 8:401-414, 1982 11. Axelrod S, Schnipper OL, Rau JH: Hospitalized offspring of Holocaust survivors: problems and dynamics. Bull Menninger Clin 44:1-14, 1980 12. Frank1 VE: Man’s Search for Meaning. New York, Pocket Books, 1975 13. Lee BS: Holocaust survivors and internal strengths. J Hum Psychiatry 28:67-96, 1988 14. Dimsdale JE: The coping behavior of Nazi concentration camp survivors. Am J Psychiatry 131:792-797, 1974 15. Cassel EJ: The nature of suffering and the goals of medicine. N Engl J Med 306:639-645, 1982
269
Shimon Waldfogel,
M.D.
Abstract: During medical or psychiatric hospitalization, Nazi Holocaust survivors may display emotional symptoms that reflect the psychological sequelae incurred by their traumatization. What is often less recognized is the idiosyncratic responses that may be seen in the children of these survivors in response to physical illness and hospitalization. Psychiatrists should be alert to the possible effects of Holocaust-related experiences. Awareness of emotional conflicts, defenses, and strengths in these individuals may enhance the therapeutic alliance as well as treatment planning. The author describes two cases illustrating adaptive and maladaptive manifestations of the Holocaust theme in response to medical illness.
Introduction It is well documented that the psychological impact of the Holocaust can be passed from survivors to their children [l-g]. The interplay of the Holocaust experience and serious medical illness and hospitalization in survivors themselves [9,10], as well as the idiosyncratic response to psychiatric hospitalization in their offspring, have also been described [ll]. Nonetheless, the psychiatric literature rarely profiles the particular stresses of physical illness and medical hospitalization in survivors’ children. “Intergenerationally transmitted’ [5] psychological sequelae of their parents’ Holocaust experiences may significantly influence the response of survivors’ children to their own physical illnesses and hospitalizations. As these individuals are reaching middle age and beyond, with the resultant increase in morbidity, such reactions may be more commonly seen by the physician in the medical setting. The lack of awareness in the psychiatrist of the
From the Department of Psychiatry and Human Behavior, Jefferson Medical College, Philadelphia, Pennsylvania. Address reprint requests to: Shimon Waldfogel, M.D., Department of P~ychiatryLandHuman Behavior, Jefyerson Medical College, 11th and Walnut Streets, Philadelphia, PA 19107. GeneralHospital Psychiatry
13, 267-269, 1991 0 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
relationship of these underlying factors to the expression of symptoms can lead to misdiagnosis and to the omission of potentially beneficial interventions. The following two cases illustrate the incorporation of the Holocaust theme into the psychological responses of survivors’ children to physical illnesses. The Holocaust theme, as these examples show, can be used for adaptive or maladaptive coping patterns in those with physical illnesses.
Case 1 Ms. A, a 42-year-old Jewish, married mother of two children, was seen in psychiatric consultation for severe anxiety during a hospitalization due to a thrombus of the inferior vena cava. Ms. A was initially reluctant to speak with the psychiatrist and was surprised that such a consultation was requested. An evaluation revealed that she was the only child of Holocaust-survivor parents. Upon arrival in the United States at age 6, Ms. A had quickly assumed the role of “parent” to her mother. Her rapid acquisition of English helped foster dependency of her parents upon her. Both parents had died prior to her hospitalization; her father 10 years before, and her mother 5 years before after surviving for several months after a cerebrovascular accident. Ms. A cared for her mother during the illness. The morning after her mother’s death, she reported feeling “I was my mother.” In the 5 years after her mother’s death, she developed symptoms of asthma and diabetes mellitus, both of which were illnesses her mother had. Following surgery to evacuate the thrombus, Ms. A developed a transient delirium and became extremely anxious, hypervigilant, and paranoid. She insisted on having her family stay with her. The delusional content of her delirious thoughts seemed to be related to her parents’ Holocaust experiences. Ms. A felt that she was in a concentration camp similar to the one her mother had experienced. She also ex267 ISSN 0163~8343/91/$3.50
S. Waldfogel
pressed fear of the nurses and doctors, whom she identified as Nazis. Regular reorientation by the staff, acknowledgment and discussion of her fears regarding her medical situation, and empathic clarification regarding the connection of her psychiatric symptoms with her parents’ Holocaust experiences helped greatly to reduce her symptoms of paranoia and anxiety. Her delirium cleared without medication within I2 hours.
Case 2 Mr. B was a 34-year-old, single, Jewish son of Holocaust survivors, who was found to have Hodgkin’s lymphoma soon after his arrival from an Eastern European country to pursue graduate studies in the United States. Mr. B did not inform his parents of his illness, noting “I didn’t want to burden them after what they went through.” During the subsequent radiation treatment, he began to experience weakness, nausea, vomiting, and weight loss. He felt like “the living death,” and said, “I have nothing left, I have lost the feeling of existence,” When his hair began falling out, he referred to the experience as “my Holocaust.” During psychiatric interview, Mr. B recalled his father’s accounts of the concentration camp. He remembered in particular his father’s reactions to his first encounter with death: an increased identification with the suffering and survival of the Jewish people and “a joining with Jewish existence and its tradition of survival.” Mr. B began to employ the same coping mechanism in response to his own “Holocaust” as his father had used in his concentration camp experience. Through this identification, he reported “feeling stronger, and gaining energy and strength.” He sensed a change in his world view; he became more spiritual and experienced a rekindling of the search for his Jewish roots. Mr. B’s father had been in the concentration camps at approximately the same age that Mr. B was struggling with his illness. Though the Holocaust was discussed often in his childhood home, his father’s personal experience in the camps was talked about only upon Mr. B’s request when he was 25 years old. Mr. B’s primary psychological response to a potentially catastrophic illness revolved around his identification with his father as a survivor rather than as a victim. This positive identification gave emotional meaning and strength to his suffering and thus became an adaptive way to cope with his illness.
Discussion The psychiatric literature has had numerous descriptions of the emotional difficulties experienced by children of Holocaust survivors as they undergo 268
the individuation process [l-5]. These children may grow up to be their parents’ “bridge back to life” [4], and often carry the burden of trying to vindicate their parents’ suffering. They also frequently experience conflicts in identification with parents, either as degraded victims or as omnipotent survivors [3,4]. The parents’ pervasive silence about their traumatization may paradoxically intensify Holocaust-related fantasies and positive and negative identifications resulting from these fantasies [4]. The delusional thought content of Ms. A’s delirium was based upon an identification with her parents as Holocaust victims. The intensive care setting was perceived by her to be a concentration camp and its staff as Nazis. The sense of helplessness that accompanies severe illness and hospitalization may symbolically represent incarceration in concentration camps for Holocaust survivors and their children [5,11]. These individuals may therefore have difficulty trusting health care professionals, especially those who are not Jewish [3]. Some extreme cases may benefit by involving a Jewish physician or nurse who can directly address the patients’ concerns. A particular resistance to psychiatric evaluation may be evident out of fear of being labeled “crazy,” which resulted, in the camps, with being promptly sent to the gas chambers 151. Mr. B’s response to his illness, through identification with his father as a survivor, demonstrates the adaptive use of the Holocaust theme. The sense of transcendence in Holocaust survivors’ reactions to concentration camp experiences, as well as the survivors’ use of the concentration camp experience in an adaptive manner, have been described elsewhere [12-141. The utilization of transcendence as an adaptive coping mechanism by the survivors’ children has rarely been described. Cassel [15] noted that “transcendence is probably the most powerful way in which one is restored to wholeness after an injury to personhood. When experienced, transcendence locates the person in a far larger landscape. The sufferer is not isolated by pain but brought closer to a transpersonal source of meaning and to the human community that shares those meanings. “ Problems with separation issues may also be prominent for Holocaust survivors and their children. In the Holocaust, separation often assured never seeing one’s family members again [5]. For some Holocaust victims and their children, hospitalization may be the first extended separation
Illness in Children of Holocaust Survivors
from their home and family, thus reactivating a powerful sense of potential vulnerability. Nevertheless, some individuals like Mr. B may be reluctant to further burden their parents or others with their own emotional needs, fearing that they will add to or reawaken their parents’ or others’ suffering. Separation in the form of hospitalization thus assumes a doubly poignant significance for them; there is increased risk, but also a reluctance to discuss this among the family members, often coupled with a lack of conscious awareness of these factors.
Summary Idiosyncratic psychological reactions incorporating the Holocaust theme may emerge during medical or psychiatric hospitalizations of offspring of Holocaust survivors. Psychiatrists should be alert to the possible manifestation of the intergenerationally transmitted effects of Holocaust-related experiences. Awareness of these individuals’ emotional conflicts, defenses, and strengths in these areas, may facilitate the opportunity to form a therapeutic alliance with them. An understanding of the vulnerability that Holocaust-related trauma creates may help the psychiatrist diagnose and develop treatments that enhance these individuals’ ability to cope with the stress of their illness and hospitalization. The informed psychiatrist can better help patients, their families, and medical treatment teams to understand the manifested response. Drawing upon the offspring’s identification with the parent as a survivor may enhance the patients’ ability to cope with their illness in some cases. When indicated, empathic, reassuring, and yet indepth exploration of these issues with the patient may significantly relieve the symptoms that led to the psychiatric consultation and even improve their cooperation with further necessary medical treatments. Such dynamically informed psychiatric consultation may additionally prepare them for future psychotherapy, if needed, which may enable a greater integration of the Holocaust experience into other aspects of their lives.
The author would like to thank Salman Akthar, M.D., Troy L. Thompson II, M.D., and Paul Root Wolpe, Ph.D., for their helpful comments on the manuscript.
References 1. Barocas HA, Barocas CB: Manifestations of concentration camp effects on the second generation. Am J Psychiatry 130:820-821, 1973 2. Barocas HA, Barocas CB: Separation-individuation conflicts in children of holocaust survivors. J Contemp Psychother 11:6-14, 1980 3. Phillips RE: Impact of Nazi Holocaust on children of survivors. Am J Psychother 32:370-378, 1978 4. Levine HB: Toward a psychoanalytic understanding of children of survivors of the Holocaust. Psychoanal Q 51:70-92, 1982 5. Danieli Y: Treating survivors and children of survivors of the Nazi Holocaust. In Ochberg FM (ed), Post-Traumatic Therapy and Victims of Violence. Psychosocial Stress Series No. 11. New York, Brunner/Mazel, 1988, pp 278-294 6. Link N, Victor B, Binder RL: Psychosis in children of Holocaust survivors: influence of the Holocaust in the choice of themes in their psychosis. J Nerv Ment Dis 175:115-117, 1985 7. Solomon Z, Kotler M, Mikulincer M: Combat-related posttraumatic stress disorder among secondgeneration Holocaust survivors: preliminary findings. Am J Psychiatry 145:865-868, 1988 8. Rosenthal PA, Rosenthal S: Holocaust effect in the third generation: child of another time. Am J Psychother 34:572-580, 1980 9. Baider L, Sarell M: Coping with cancer among Holocaust survivors: an exploratory study. J Hum Stress 10:121-127, 1984 10. Edelstein EL: Reactivation of concentration camp experience as a result of hospitalization. Ser Clin Community Psycho1 Stress Anx 8:401-414, 1982 11. Axelrod S, Schnipper OL, Rau JH: Hospitalized offspring of Holocaust survivors: problems and dynamics. Bull Menninger Clin 44:1-14, 1980 12. Frank1 VE: Man’s Search for Meaning. New York, Pocket Books, 1975 13. Lee BS: Holocaust survivors and internal strengths. J Hum Psychiatry 28:67-96, 1988 14. Dimsdale JE: The coping behavior of Nazi concentration camp survivors. Am J Psychiatry 131:792-797, 1974 15. Cassel EJ: The nature of suffering and the goals of medicine. N Engl J Med 306:639-645, 1982
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