Orthodox Jewish Occupational Therapy Chavrusa

Aging After Virtual Death - Rehab Concerns With Holocaust Survivors

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Vol. 23 •Issue 10 • Page 39

As a Jewish educator and an occupational therapist, I have been in the rare situation where I can use both of these talents to better understand, approach and address some unique aspects of aging of survivors of the Holocaust of the Jews.

But what began for me as an anecdotal, observational aspect of care has evolved into a researched and systematic understanding of the unique concerns of this now-geriatric population.

I have worked with the aged for over 30 years, seven of which have been solely dedicated to working with the special-needs population; I spent the last three-and-a-half years working in an environment with aging Jewish community members.

As the daughter of a member of the remnant of Polish Galician Jews, I had the unique opportunity of going to my father's hometown in Poland and subsequently studying for one week at an educators' seminar at Yad VaShem in Jerusalem. It was there that I met and spoke with another OT who had been studying the effects of this community's aging process and its impact on their lives.

What to Look for

Survivors and their families are often a close—and closednetwork of people. They are resistant to services that appear to compromise their self-image of self-reliance, independence and resourcefulness. Many have values and attitudes inculcated into their persona from their pre-war community that also impacts their response to treatment. They often arrived in this country with little or no extended family, finances and relevant cultural skills.

I often marvel how my father, now 86, left a community as a teenager with no electricity, cars, running water or modern conveniences, to come to a country where this was all taken for granted. Interactions and physical contact between the sexes was often very modest and constrained, making current hands-on medical practices feel very alien and uncomfortable.

Lack of access during the Holocaust to food, adequate shelter, decent working conditions and health care for such an extended period of time adds an element of unprecedented deprivation to the trauma of this captivity. Medical care in the camps was often a perversion and now causes some survivors to be wary of unfamiliar caregivers, and associate what can be perceived as "rough treatment" as anti-Semitic behavior.

This, then, creates a background onto which caregivers must afford effective treatment. Careful research into studies that have been done offers a number of approaches that can help in advancing this effort.

Understanding the Factors

Myra Giberovitch, coordinator of services for Holocaust Survivors Jewish Support Services for the Elderly in Montreal, has summarized these factors in her "Agenda for the Future." Her studies indicate that survivors of the Holocaust rarely seek mental-health or social-service assistance, and are often reluctant to accept help when offered.

Their pre-war lives' coping skills stressed self-reliance, modesty and self-determination, which often impact on their ability to negotiate the systems, ask for assistance and/or accept help when offered. Help reflects an image of weakness, dependence and humiliation that is unacceptable to them in the face of adversity.

There are some who harbor a feeling of anger toward their "new" home country for failing to come to their aid as millions suffered and died. When there are few, if any, other surviving family members, a feeling of "survivor guilt" was reposted in a study by Aaron Hass of California State University, Dominguez Hills, CA.

A study done for a 2004 article for the Journal of Nutrition Education and Behavior by Amy J. Sindler, MS, RD, Nancy S. Wellman, PhD, RD, FADA, and Oren Baruch Stier, PhD, highlighted long-term effects on attitudes toward food. Europeans forced into ghettos and labor and/or concentration camps had food harshly distributed.

Ration cards were the official source of food distribution in the ghettos, although there was a black-market trade and community soup kitchens supplementing those meager rations. If the statistics of the Warsaw Ghetto are typical, 15 to 18 percent of the people living in the ghettos starved to death. In the camps, inmates were fed diets of highly diluted soups, scraps of bread and "coffee," and often resorted to bartering for food and eating grass, leaves, scraps and vermin, and even occasionally resorting to cannibalism.

Their captors anticipated that the survival rates would not exceed three months as the prisoners lived off their stores of body fat and muscle.

An Italian study indicates that a higher percentage of binge eating was evident among Nazi concentration camp survivors as compared to their peers in a control group of similar age and gender. The survivors all reported that their experiences influenced their current attitudes toward food and how and what they eat. Many indicated that their experience in the camps with hunger was incomparable to our current understanding.

Five main themes emerged from this study, showing that these Holocaust survivors:

  • had difficulty throwing food away, even when it was spoiled;

  • were storing excess amounts of food;

  • craved certain foods;

  • had difficulty standing in line for food; and

  • experienced anxiety when food was not readily available.

    However, all indicated that they feel they must fast when religiously obligated on holidays.

    Compounding all of these unique concerns are the normal sociological, medical and environmental impacts of aging that affect the whole of the population. There is not a monolithic profile of the survivor; however, the uniqueness of this formative experience does provide us with some commonality of concerns when approaching the process of rehabilitation and restorative care.

    A large piece of the approach must be education:

  • of the recipient of care,

  • of the providers of personal care, and

  • of providers of rehabilitative and restorative services.

    I felt compelled by having the unique experiences and educational advantages of being both therapist and Jewish educator to advance that effort.

    On a Collision Course

    An individual arrives at the point of needing rehabilitation services most generally because their physical capacity is diminished, they can no longer perform occupationally, and they have difficulty with bathing, dressing, decision making, mobility/ambulation and/or self-feeding.

    Capability in these areas represented the ability to survive in their prior life experiences. Conversely, inability to do them was a sure death sentence. Survivors need to recognize that their past reality was not personal but generalnot under their controland that it no longer controls them.

    Care providers also must realize that this past experience is, indeed, still a part of who their care recipients are, and it will always be so, despite the passage of time. This is not something that they can be expected to just "get over."

    I would like to focus on how specific life skills continue to affect the outcome of treatment and impact quality of life for the aging Holocaust survivor.

    Personal Care

    Nurses, aides and therapists are all highly trained in providing care and supportive services for their patients. But the over-emphasis Holocaust survivors may place on the need for personal dignity, reducing a sense of humiliation, and independent decision-making cannot be overestimated. Many areas of personal care also have unusual implications and innuendo to the aging survivor.

    A case in point: an elderly man, Max, a Polish Jewish survivor who had been a cantor in Europe, was admitted to a small nursing home local to his daughter. He had been living alone in his own apartment up until then, in a predominantly Jewish community, and did not appear particularly clean, well-dressed or shaved upon his admission on a Sunday.

    I was advised on arrival to work on Monday of the great "row" that this gentleman caused on admission. Could I assess his self-care ability more easily as I share a common Jewish bond with him? He tearfully told me of how they had brought him into his new room and very "roughly" assisted him to undress. They took him to take a shower and then they shaved off his beard because they felt it was very dirty.

    The parallels were immediately apparent to me with his past life experiences. The caregivers in this rural New Jersey community could not have known or understood his pain.

    As I was not present, I do not know how it could have been handled with less trauma. I am sure the staff was not "rough" but attempting to assist him in a timely manner. Would he have accepted an explanation by staff prior to the process? Possibly, if he would have believed them.

    Awareness, at least as it would have clarified to the staff the connections of their actions with his past experiences, would have enabled them to better understand his reaction, modify their tactics or approaches, and/or incorporate other individuals, perhaps even clergy, to facilitate care.

    Activities of daily living such as showering, removing clothing in the presence of others—particularly members of the opposite sex—cutting off the beard or hair, and being handed or dressed in institutional clothing all trigger difficult memories. Caregivers should use alternative means of achieving hygienic conditions, assuring healthful cleanliness and guaranteeing a sense of self-reliance and independence, even in the event of neediness, for such individuals.

    Self-feeding

    It is not uncommon to see aging survivors taking food from their tables and hording it in wheelchairs, under cushions, in bedrooms or nightstand drawers. While caregivers can explain to them that this can be a health risk due to possible infestations of mice or bugs, it is not reasonable to expect that cautionary words will extinguish the behavior.

    A survivor of Buchenwald with Parkinson's disease and a new diagnosis of dysphagia was having significant difficulty. He received both speech and occupational therapies for his mealtime concerns. At each meal he brought up food concerns of the camps: the requirement to eat non-kosher food by his captors, the scarcity of food and liquids, and the lack of taste. His daughter, concerned about her father's apparent disdain for the food provided (pureed and thickened liquids), would "sneak in" foods to his liking, but which put him at increased swallowing risk. Care staff would become angry with her for not adhering to food guidelines and swallowing concerns.

    The dietitian and speech therapist began diet and swallowing education to the family with the patient present, to assure that he understood the transparency of diet selection, consistency and flavors. His daughter was allowed to sit with him in the dining room during the meal to permit him the social acceptability of his meals and reduce the anxiety associated with food presentation and feeding needs.

    Ambulation

    Mobility—in the camps, in hiding places and in the woods—was the basis of staying alive. Sound legs, walking unaided and lack of fatigue allowed one to live another day.

    The ability to stand for extended periods during roll calls, camp checks and work assignments could not be underestimated. When rehabilitation, nursing and care staff then tell you that it is unsafe for you to walk; that you must use a walker or wheelchair; and when alarms are attached to you, your clothing or your bed/wheelchair that go off when you attempt independent ambulation, flashes back to a former time are inevitable. Rejection of therapy services may result.

    Refusal to use safety devices or use a call bell for assistance, or removing safety alarms, is commonplace. These people often express a need to walk freely about but also a fear of lack of familiarity with the locations in which they are walking (how to get out if it would become necessary).

    It is often necessary to work in private, inconspicuous locations with Holocaust survivors. This affords them dignity and allows them not to feel humiliated by their inabilities. Use of comfort measures, like moist heating pads, massage and gentle stretching prior to the challenge of standing and walking, make this process less threatening. Functional ambulation such as walking to a meal or to the bathroom is generally better accepted than going through ambulation as an end in itself. This type of "mindless, purposeless" walking can easily trigger memories of previous walking and standing tortures.

    A very alert and always edgy woman was a resident at the Jewish home where I worked. She was a constant walker, and had the habit of counting the steps she took all during the day. She told the therapy staff that her father taught her to do this as a young child to make walking in their mountainous home community less stressful. She attributes this tactic with saving her life during the Nazi death marches and continues to this day to thank her father for "keeping her alive."

    Therapeutic Recreation

    As was mentioned earlier, even those who suffered the enforced, never-ending fast of the Nazi occupation continue to observe ritual fasts for religious reasons. This and many other examples of religious resistance—that is, performance of ritual despite the risks of death if caughtreflect the importance of religion, religious practice and customs as meaningful parts of Holocaust survivors' lives.

    Many think that Holocaust survivors abandoned religious practice as a statement of despair and a feeling of abandonment by God and by fellow Jews. But statistics tell us otherwise. Most aging survivors practice some level of traditional practice of Judaism. Many are volunteers at Holocaust memorials, hospitals or schools, sharing their experiences and memories so that others will not experience this horror.

    It is especially relevant that Jewish practices, traditions and holidays are highlighted. Many who were forced into hiding these practices in the past feel empowered by the ability to do them openly now. Some are also intimidated by certain holidays that were often opportunities for terrorizing their communities in the past, such as Easter and Christmas, when Jews were often beaten, tortured or killed as "Christ-killers."

    If the aging survivor is a resident of a local secular nursing home or skilled facility, staff should be informed of his or her particular feelings and experiences to reduce anxieties and fears.

    If it is a Jewish nursing home, care should be taken to avoid overt activities related to these holidays, emphasizing rather the cycle of the Jewish holiday year. Activities and recreation staff members should seek groups, clergy and volunteers from the local Jewish communities and schools for both guidance and programming. Religious agencies in the community, also, should not wait to be asked, but should volunteer information, decorations, music programming, friendly visitations and personal interaction as a part of their ongoing commitment to the Jewish community, for preserving the memory of the Holocaust and for honoring those who have survived it who are in their midst.

    Education

    Ongoing staff education on the unique difficulties experienced by the aging Holocaust survivor is critical. Often, caregivers, even in religiously affiliated institutions, are not themselves Jewish. They deserve the education necessary to provide quality care, to reduce patient stress and to assure quality of life for the aging Holocaust survivor.

    Nursing and in-service education staffs need to be aware of programs happening on the subject in their areas and assure that someone attends who can then educate the rest of the care staff. Local agencies such as Jewish family services, Jewish homes of the aged and synagogue groups can initiate such projects and afford a service to the caregivers of our old.

    We are all responsible for one another. How we treat the least of us is how we deserve to be remembered. Memory can be a blessing or a curse, but it is always there and a part of who we are. How we respect memory can be the determinant of how well we are able to help those in need of our services.

    Resources available at www.advanceweb.com/OT or upon request.

    Sharon Brooks, OTR/L, is an occupational therapist from Lebenon, NJ.