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This course is intended to provide an interactive experience to enhance knowledge and promote changes in the care of victims of trauma.

The experiences and insights of Holocaust survivors and those who work with them will be used to provide examples of how PCTI care may be applied to Holocaust survivors and other victims of trauma. Video simulations and historical photography are used to depict situations and circumstances. For more information, please see below:

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The material presented in this continuing education program is not intended to represent the best or only methods or procedures appropriate for the situation discussed; rather the material is intended to present an approach, view, or statement which may be helpful or of interest to other practitioners. The attendees agree to participate in this education program, sponsored by Holy Name Medical Center (HNMC) with full knowledge and awareness that they waive any claim they may have against HNMC its affiliates, directors, employees, officers, trustees, representatives and agents for reliance on any information presented in this educational program. In addition, the attendees also waive any claim they have against the HNMC for injury or other damage that may result in any way from their participation in this program. No statement or presentation made is to be regarded as dedicated to the public domain. Any sound reproduction, transcript or other use of the material presented at this course without the permission of HNMC is prohibited to the full extent of common-law copyright in such material.

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Introduction and Course Overview

This course is intended to provide an interactive experience to enhance knowledge and promote changes in the care of victims of trauma.
The focus is on the past trauma experienced and possible triggers that may cause re-traumatization in a healthcare setting.
The experiences and insights of Holocaust survivors and those who work with them will be used to provide examples of how Person-Centered, Trauma-Informed care can improve outcomes when treating Holocaust survivors and other victims of trauma.
Video simulations and historical photography are used to depict situations that may trigger re-traumatization of survivors.

Course Objectives

Differentiate Holocaust survivors from other elderly patients in a healthcare setting.
Identify situations that may trigger trauma for a Holocaust survivor during routine healthcare activities.
Explain how a person-centered, trauma-informed (PCTI) approach can be used to reduce re-traumatization of Holocaust survivors and other victims of trauma.

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Pre-Module Survey

Thank you for participating in the module. We want to hear about your existing knowledge of Holocaust survivors and patient-centered, trauma-informed care.

Please complete the survey and let us know your thoughts (your answers will be anonymous). Please rate the questions on a scale of 1 to 5.
(1 = no knowledge, 2 = minimal knowledge, 3 = average knowledge, 4 = above average, 5 = superior knowledge)

Rate your knowledge of the Holocaust

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Rate your knowledge of the treatment of Jewish citizens during the Holocaust

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Rate your ability to identify persons who experienced a traumatic event

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Rate your knowledge of triggers in a healthcare environment that may re-traumatize survivors

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Rate your knowledge of the principles of trauma-informed care

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Basic facts about the Holocaust

The Holocaust refers to the state-sponsored persecution and murder of six million European Jews by Nazis Germans and their collaborators during World War II.
It began in 1933 after Hitler became chancellor in Germany and continued as Germany invaded other European countries and the Soviet Union until Germany surrendered in 1945.
For most of us, this seems so long ago, something that was learned in history class. Even the memories of survivors of this genocide are becoming history.
The Holocaust was very real and horrific; inflicting the worst kind of trauma with long range physical and psychological effects.
The frail, elderly survivors ,many who were children during these years, are still alive today living throughout the world.

Who are the Holocaust Survivors?

Anyone who had at least one Jewish grandparent and lived under the Third Reich or German Occupation from 1933 – 1945 .Holocaust survivors come from all over Europe and the former Soviet Union. This includes:

People imprisoned in labor and concentration camps
People living in ghettos
People who escaped to other countries
People who lived under false identities
Adults and Children who lived in hiding
Emigres from the former Soviet Union

Holocaust Survivors

More than 80,000 Holocaust survivors currently live in the United States.
Today these survivors are more than 75 years of age, with the majority of the survivor population having been children under 13 when Germany invaded.
Half of the survivors live in the NY Metro Area and the others are concentrated in Miami LA, Chicago and other large cities. More than 30% of them live below the poverty level.
Holocaust survivors experienced horrific trauma, both physically and psychologically.
Some elderly survivors will not speak of their experiences, while others think it is important to share their stories.

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Today's Survivors Case Study 1 of 7

A million and a half Jewish children were murdered during the Holocaust. Six to eleven percent of Europe’s prewar Jewish children survived as compared to 33% of the adults. The surviving children escaped death because they were hidden. Often their identities were disguised or they were physically concealed from the world. The hidden children lived in fear and danger. Jewish parents sent their children unaccompanied to live in other countries or to live with Christian families or Christian convents. Children were sent from the cities to farms. Other children were hidden in closets, attics, cellars, and sewers. Sometimes for months or years. In hiding, the children adopted new names, languages and customs. Another group of children were abandoned altogether, forced to learn how to survive on their own.

At war's end, many of the "lucky" children, the last survivors to bear witness to the Holocaust, could not be reunited with family. Some were never told of their true identity or actual birthday, since they often had to lie about their age to survive in the concentration camps. These hidden children developed psychological scars from a traumatic wartime experience and perceived abandonment by their parents.

Knowledge Check Question 1 of 7

Jewish children during the Nazi occupation of Europe were safe, kept with family members and are free from psychological trauma as adults.

True

False

Please select one!

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Correct

Rationale:

Often their identities were disguised or they were physically concealed from the world. The hidden children lived in fear and danger. Jewish parents sent their children to live with Christian families or Christian convents. Children were sent from the cities to farms. Other children were hidden in closets, attics, cellars, and sewers. Sometimes for months or years. In hiding, the children adopted new names, languages and customs. Another group of children were abandoned altogether, forced to learn how to survive on their own. At war’s end, many of the children could not be reunited with family. Some were never told of their true identity. The children have psychological scars from a traumatic wartime experience and perceived abandonment by their parents.

Incorrect

The correct answer is False. Please correct your answer and try again.

Rationale:

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Why is understanding the Holocaust experience important?

The aging process of Holocaust survivors is different from other elderly persons because of the trauma they experienced.
Survivors of trauma can be easily re-traumatized by everyday activities, especially when accessing healthcare services.
Routine visits with doctors and dentists can become triggers that evoke past memories of persecution.
Few medical and dental professionals have training in treating Holocaust survivors nor do they understand the possibility of re-traumatization.

Meet a Holocaust survivor and hear her story as just one example of thousands more Case Study 2 of 7

I Survived The Holocaust Twin Experiments - Eva's story

Permission granted from CANDLES Holocaust Museum and Education Center candlesholocaustmuseum.org

Knowledge Check Question 2 of 7

Which of the following are examples of how survivors were treated during the Holocaust?

A. Forced to participate in unexplained medical experiments

B. Injected with unknown substances

C. Subject to frequent, unexplained blood tests

D. Restrained to examination tables

E. All of the above

Please select at least one option!

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Correct

Partial Correct

The correct answer is E. Please correct your answer and try again.

Incorrect

The correct answer is E. Please correct your answer and try again.

Rationale:

Eva tells the story of her experience as a child in the Auschwitz concentration camp. She and her twin sister were separated from their family. The were restrained and injected with multiple unknown substances. Blood was taken from them frequently.

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What is Trauma?

All Holocaust survivors experienced trauma, although each is an individual with a different story.
"Individual trauma results from an event or set of circumstances that is experienced by an individual physically or emotionally harmful or life threatening and has lasting adverse effects on the individuals functioning and mental physical, social emotional or spiritual well-being." (Substance Abuse and Mental Health Services Administration, 2014).
Triggers that evoke the past traumatic experiences can erupt at unexpected times. Even the slightest hint of danger can trigger re-traumatization.
Anything can trigger re-traumatization: Sensory-related stimuli (smell, touch, taste sound) reminders of past experiences, memories that suddenly resurface.

Knowledge Check Question 3 of 7

What are the elements of trauma? Select all that apply.

1. It can be experienced as both physically and/or emotionally harmful

2. It has long-lasting adverse effects

3. It can be reactivated or triggered, long after the experience is over

4. It is easy to erase the effect of trauma

Please select at least one option!

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Correct

Rationale:

Individual trauma results from an event, or series of events, that is experienced by an individual as physically or emotionally harmful or life-threatening, and has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual well-being.

Partial Correct

The correct answer is 1, 2, and 3. Please correct your answer and try again.

Rationale:

Individual trauma results from an event, or series of events, that is experienced by an individual as physically or emotionally harmful or life-threatening, and has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being.

Incorrect

The correct answer is 1, 2, and 3. Please correct your answer and try again.

Rationale:

Individual trauma results from an event, or series of events, that is experienced by an individual as physically or emotionally harmful or life-threatening, and has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being.

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Routine Healthcare Activities

Without understanding the experiences of a Holocaust survivor, routine activities in a healthcare setting can easily trigger trauma:

Visiting a doctor or dentist for a check-up may be incorrectly associated with serious illness or death, rather than routine or preventative care.
Filling out intake paperwork causes anxiety because many do not know their exact age, as it was changed, or do not have a birth certificate.
Loud noises from a dentist drill, dropped metal object, banging of an MRI machine can result in an extreme overreaction.
Being asked to undress and put on a hospital gown can be a reminder of the loss of control and identity that they experienced in a concentration camp.
Taking a blood pressure or pulse, without being informed or getting consent, can make them feel victimized.
Giving directives like stand straight, sit down in a harsh tone can make them feel unsafe.

Common Reactions to Triggers

Nightmares and flashbacks
Irrational fears or an exaggerated response
Withdrawal from relationships and activities
Irritability, anxiety, and depression
Sleep disturbances
Panic, paranoia or rage

Trauma and Fear of Healthcare Providers

For Holocaust survivors even routine healthcare can trigger feelings of extreme anxiety and fear.
The trauma they or their family's experienced during the war is re-lived in the dentist chair, doctor's office or hospital.
The association for many of these people is that “being ill” means being selected by Nazi doctors to be killed because sick prisoners could not work.
During the Holocaust doctors conducted painful and deadly experiments on prisoners without their consent. Even those not living in camps knew about these gruesome events.
Nazi dentists extracted teeth for the gold using painful tools without anesthesia.
Young children, especially twins, were taken away from their parents and were part of painful medical experiments.

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Triggers Case Study 4 of 7

Healthcare providers who don't know the history of their patients can unintentionally cause re-traumatization through simple questions, or requests.

Triggers are objects or events that trigger a memory causing re-traumatization for Holocaust survivors or others who have endured trauma.

Please watch this video of a Holocaust survivor going to the hospital for a MRI.

Knowledge Check Question 4 of 7

Enter the corresponding letter to match the traumatic experience of a Holocaust survivor on the left with the current trigger on the right.

Please match at least one option!

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Correct

Rationale:

During the Holocaust, incarcerated persons were stripped of their own clothes and given uniforms to wear in the camps. Asking a patient to disrobe and put on a hospital gown may trigger the memory of the uniform.

Healthcare providers in white coats who examine or treat a Holocaust survivors without permission or an explanation trigger a memory of the medical experiments of the Holocaust.

Holocaust survivors were injected with unknown substances. Giving a survivor an injection or immunization may trigger the memory of the injections given during their imprisonment.

Giving a hospitalized Holocaust survivor a small meal on a tray may trigger the memory of rationed food.

Partial Correct

The order of the correct answers is D, A, C, B. Please correct your answer and try again.

Rationale:

During the Holocaust, incarcarated persons were stripped of their own clothes and given uniforms to wear in the camps. Asking a patient to disrobe and put on a hospital gown may trigger the memory of the uniform.

Healthcare providers in white coats who examine or treat a Holocoaust survivors without permission or an explanation trigger a memory of the medical experiments of the Holocaust.

Holocaust survivors were injected with unknown substances. Giving a survivor an injection or immunization may trigger the memory of the injections given during their imprisonment.

Giving a hospitalized Holocaust survivor a small meal on a tray may trigger the memory of rationed food.

Incorrect

The order of the correct answers is D, A, C, B. Please correct your answer and try again.

Rationale:

Healthcare providers in white coats who examine or treat a Holocoaust survivors without permission or an explanation trigger a memory of the medical experiments of the Holocaust.

Holocaust survivors were injected with unknown substances. Giving a survivor an injection or immunization may trigger the memory of the injections given during their imprisonment.

Giving a hospitalized Holocaust survivor a small meal on a tray may trigger the memory of rationed food.

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How Healthcare Professionals Can Care for Survivors

Providers caring for survivors of the Holocaust need a heightened awareness of the risk of re-traumatizing their patients.

An opportunity was identified to create a model of care that could be applied not just to one population, but to the many other survivors of traumatic events around the world. The model is person-centered trauma-informed (PCTI) care.

What is Person-Centered, Trauma-Informed (PCTI) Care?

“A holistic approach to service provision that promotes the dignity, strength, and empowerment of trauma victims by incorporating knowledge about the role of trauma in victims’ lives into programs, policies, and procedures”.
PCTI Care recognizes the effects of trauma on the physical and psychological health of an individual.
Requires an understanding of a person’s life experiences in order to deliver effective care.
A model of healthcare service designed to reduce the risk of re-traumatizing those who have been victimized including the survivors of historical trauma around the world such as refugees and veterans.

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Survival, but with a price on physical and mental health Case Study 5 of 7

Please watch this interview With Dr. Barbara Paris explaining the health-related issues of Holocaust survivors.

Dr. Barbara Paris is the Director of Geriatrics and Vice Chair of Medicine at Maimonides Medical Center in Brooklyn, NY. Dr. Paris has performed research and published throughout her career discussing the topic of treating depression in the elderly. She has worked extensively with Holocaust survivors and is an expert in the field of PCTI care.

Knowing a Person is a Holocaust Survivor

It is important to know if your elderly patient is a Holocaust survivor, although not always obvious, in order to avoid triggering trauma during a healthcare visit.
Some survivors will self-identify upfront, “I am a Holocaust survivor”. This often means they expect special attention.
A tattooed number on someone’s arm is rare. Only those Holocaust survivors who were incarcerated in the Auschwitz concentration camp have a number tattooed on their arm.
Healthcare professional must use a combination of looking at age, where they came from in Europe, or the former Soviet Union, and what year they came to the United States to determine if their patient is a possible Holocaust survivor.

Common health-related issues of survivors as discussed by Dr. Paris:

Less educated
Fewer social supports
Unable to perform activities of daily living
Poor self-reported health
Greater use of psychiatric medications
Greater incidence of cardiovascular disease, osteoporosis, joint diseases, cancer, and dental problems
Greater chance of refusing treatments and vaccines

Knowledge Check Question 5 of 7

The lived experience of traumatic events impacts both the physical and behavioral health of survivors.

True

False

Please select one!

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Correct

Rationale:

Research documents the relationship between exposure to a traumatic event and subsequent health issues such as an increase in cancer rates, cardiovascular disease, other immune-response diseases, as well as, the elderly's cognitive functioning and behavioral health such as depression and anxiety.

Incorrect

The correct answer is True. Please correct your answer and try again.

Rationale:

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A Better Way: Person-centered trauma informed care Case Study 6 of 7

Please watch this interview with Dr. Barbara Paris explaining Person-Centered Trauma Informed Care.

PCTI Care is Complex

Providing PCTI care is complex. It involves building a trusting relationship between survivors and their caregivers by using knowledge of their personal traumatic experiences and fostering a cooperative approach with the overall goal of preventing re-traumatization.

Realize the effect trauma can have on physical and psychological health
Recognize the signs and symptoms of trauma, although not always visible
Respond by integrating knowledge about trauma in staff/ office/ policies and procedures
Resist re-traumatizing those that have been victimized in the past

The Principles of Person-Centered Trauma-Informed Care

Trauma-informed services are guided by the principles of:

safety, trustworthiness and transparency,
peer support, collaboration and mutuality;
empowerment and choice; and
sensitivity towards cultural, historical and gender issues.

Please watch this video of Dr. Sumareva explaining the components of Person-Centered Trauma-Informed Care

Dr. Sumareva is a board certified periodontist and implant surgeon in Cliffside Park, NJ and co-founder/CEO of ZiphyCare. She is president of the Russian American Dental Association(RADA) and is the NY Ambassador of the Alpha Omega/Henry Schein Cares Oral Health Program for Holocaust survivors. Dr. Sumareva has provided treatment for many survivors in her practice.

Knowledge Check Question 6 of 7

What are the four essential elements of Person-centered, trauma-informed care?

A. Realize

B. Recognize

C. Respond

D. Resist re-traumatization

E. Reflect

Please select at least one option!

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Rationale:

The 4 elements are:

realize or the understanding of how trauma can affect people,
Recognize the signs of trauma with screening and assessments,
Respond by creating programs and organizations which apply the principles of trauma-informed care, and
Resist re-traumatization by creating non-stressful environments and training.

Partial Correct

The correct answer is A, B, C, and D. Please correct your answer and try again.

Rationale:

The 4 elements are:

realize or the understanding of how trauma can affect people,
Recognize the signs of trauma with screening and assessments,
Respond by creating programs and organizations which apply the principles of trauma-informed care, and
Resist re-traumatization by creating non-stressful environments and training.

Incorrect

The correct answer is A, B, C, and D. Please correct your answer and try again.

Rationale:

The 4 elements are:

realize or the understanding of how trauma can affect people,
Recognize the signs of trauma with screening and assessments,
Respond by creating programs and organizations which apply the principles of trauma-informed care, and
Resist re-traumatization by creating non-stressful environments and training.

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Creating a person-centered trauma-informed environment Case Study 7 of 7

Visit Dr. Sumareva’s practice in this video to follow her example of PCTI care in action.

Build a person-centered trauma-informed environment by creating well lit spaces, including parking garages. Design easy wheelchair accessible paths to exam rooms and office exits.
Refine interpersonal skills with a welcoming greeting.
Be aware that basic questions such as age, date of birth, and family can create anxiety in a few survivors. Some do not know their exact age. Others changed their date of birth to be older or younger.
Ask permission before beginning any exam or treatments. Always provide an explanation.

Creating a PCTI Care Environment for Holocaust Survivors

Include the core principles of PCTI care in your practice.

Safety - Ensure that spaces are well-lit, including parking garages, and there is easy access to exam rooms and exits. Create a calm environment. In a busy office move patients to a quieter area or tell them to come on a less busy day.
Trustworthiness - Make sure all medical and support staff are aware if a patient is a survivor and trained in PCTI principles. Communication should be, respectful and compassionate. The receptionist should be welcoming since they are the first face of the healthcare experience.
Collaboration - Emphasize collaboration in treatment rather than compliance. Don't talk to a family member and exclude the patient. The patient should have a role in planning and evaluating their treatment and give them a choice if possible.
Empowerment - Encourage the patient by asking permission before beginning any exam or treatments. Always provide an explanation.
Sensitivity - Be sensitive to cultural, gender and historical issues. Be aware that routine intake questions such as age, date of birth and family medical history can create anxiety in survivors.

Knowledge Check Question 7 of 7

A common trigger for re-traumatization is injections of unknown substances. Which of the following is an example of person-centered, trauma-informed care

A. The health care provider explains the name and effect of medications being injected.

B. The healthcare provider offers a choice, and has patient agreement before medication is injected.

C. The healthcare provider offers sunglasses to minimize the effects of the bright lights needed in an examination.

D. All of the above

Please select at least one option!

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Correct

Rationale:

Building a safe healthcare experience which is trustworthy, transparent, and collaborative permits the survivor to control the situation without re-trauma.

Partial Correct

The correct answer is D. Please correct your answer and try again.

Rationale:

Building a safe healthcare experience which is trustworthy, transparent, and collaborative permits the survivor to control the situation without re-trauma.

Incorrect

The correct answer is D. Please correct your answer and try again.

Rationale:

Building a safe healthcare experience which is trustworthy, transparent, and collaborative permits the survivor to control the situation without re-trauma.

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Person-Centered Trauma-Informed Care Course Summary

Awareness of clients’ history guide treatments and discussions
Be mindful of your client’s verbal and nonverbal cues
Have patience with survivors of trauma
Be empathetic
Empower and give back control to survivors
Educate members of healthcare team

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Post-Module Survey

Thank you for participating in the module. We want to hear about your existing knowledge of Holocaust survivors and patient-centered, trauma-informed care.

Rate your knowledge of the Holocaust

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2

3

4

5
Rate your knowledge of the treatment of Jewish citizens during the Holocaust

1

2

3

4

5
Rate your ability to identify persons who experienced a traumatic event

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2

3

4

5
Rate your knowledge of triggers in a healthcare environment that may re-traumatize survivors

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3

4

5
Rate your knowledge of the principles of trauma-informed care

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5

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