1. “Ministry with Victims of Trauma, Especially from War” Jeffrey Cohen Rabbi DD DMin BCC FRSA

2. unique histories impact of early life trauma post war years of immigration, adaptation now aging

3. The Pastoral Process each story is unique each person is different there are no rules or guidelines to follow when caring for aging Survivors there are certain vulnerabilities and attitudes

4. Vulnerability to loss and illness Holocaust Survivors may be particularly vulnerability to experiences that are part of the aging process, –loss, –separation, –illness or –institutionalization there was no opportunity to grieve or mourn

5. Need to “bear witness” Survivors want to ensure that the Holocaust not be forgotten by future generations need to bear witness and document personal testimonials Survivors are ‘living witnesses’ but not necessarily historians

6. Absence of Kin Aging Survivors without kin may be a group at risk truly alone in the world- may rely on other survivors who constituted their ‘substitute’ families

7. Attitudes to doctors/health care professionals Doctors in the Concentration camps performed selections –supervised the killings in gas chambers –ordered, directed and carried out direct killing of debilitated patients by means of phenol injections –doctors selected people to participate in a range of medical experiments in the name of research

8. Attitudes to Institutionalization For many this is not the first experience with the loss of home, family, community, privacy and freedom Memories of transportation to camps and ghettos may be reawakened

9. Environmental Factors that Trigger Difficult Memories Reminders of the trauma of the Holocaust are always present – different ones for different people Caregivers need to be aware of the more common triggers, and appreciate that even common triggers recall unique and different memories

10. Traditional Process Event or Trigger Potential Reaction Reason

11. Potential Triggers for Holocaust Survivors Event or Trigger Potential Reaction Reason Possible Responses

12. Potential Triggers for Holocaust Survivors- an Example Event or Trigger –ER- identity bracelet with patient number Potential Reaction –Screaming/ Uncooperative Reason –Nazis dehumanised by referring only by number- also many have numbers tatooed on arm Possible Responses 1.Patient encouraged to put ID bracelet on themselves 2.2 ID bracelets used

13. Trauma and War Initial focus on survivors of the Shoah (Holocaust) Realised that both those who fought as well as those who were victims carried “baggage” Multifaceted challenge

14. Applicability beyond the sample both Veterans and Holocaust Survivors exhibit most of the same physical symptoms of ageing They cannot always be easily identified in an emergency setting where much of this care occurs focus of triage is on immediate clinical care while psychological trauma and its associated behavioural manifestations are not always easily distinguished in this environment

15. Implications for Care stress experienced by patients is compounded in staff who have not had the training or developed the processes or institutional experience to effectively manage patients with these issues Co-morbid factors such as dementia are also complicating the provision of care to those patients exhibiting trauma-related symptoms the range of behaviours exhibited by these patients in selected clinical and non-clinical contexts (e.g. aggression, food hoarding, fear of personnel) as well as the problems associated with issues around decision- making, existing co-morbid conditions, appropriate referral mechanisms