The COVID-19 pandemic has threatened the health and well-being of older adults around the world, but certain subgroups, such as trauma survivors, could be more affected than others as they may face once again a threat to their health and their lives. Holocaust survivors (HSs) constitute a particularly vulnerable group of trauma survivors since they often report increased posttraumatic symptoms (PTSs) and psychological distress compared to non-HS comparisons. At the same time, however, they display general resilience, which helps them live productive and meaningful lives (Barel etal., Reference Barel, Van IJzendoorn, Sagi-Schwartz and Bakermans-Kranenburg2010; Ohana etal., Reference Ohana, Golander and Barak2014). The COVID-19 pandemic may pose a specific threat to HS, as it could remind them of past traumas from the Holocaust. Recent research has suggested this is the case and highlighted that some HS are more vulnerable in the face of the pandemic, especially those with high PTS (Maytles etal., Reference Maytles, Frenkel-Yosef and Shrira2021) and those who contracted an infectious disease during the Holocaust (Shrira etal., Reference Shrira, Maytles and Frenkel-Yosef2020). Given the vulnerabilities of HS in the pandemic, we should ask which factors promote resilience and improve their coping.
Within this context, Bergman etal. (Reference Bergman, Maytles, Frenkel-Yosef and Shrira2021) have written an important paper on the potential sources of resilience among HS. Specifically, they address the question of whether engaging in activities during the pandemic is related to less psychological distress among HS. Previous research has demonstrated that among trauma-exposed adults, engaging in planful problem-solving activities is associated with reduced distress (Hansen and Ghafoori, Reference Hansen and Ghafoori2017). Furthermore, planful problem solving is a prominent feature in the narratives of survivors both during and after the Holocaust (Suedfeld etal., Reference Suedfeld, Krell, Wiebe and Steel1997). The study by Bergman etal. underlines the importance of activity engagement as a means of coping with external negative events and yields important results in view of future research and practice with vulnerable older populations.
Data for this study were collected from 131 older Jewish Israelis aged 76+ years, between April and June 2020. During this period, COVID-19 restrictions were gradually lifted and were not reintroduced until July 2020. The sample was divided into HS with either high or low PTS and comparisons (not directly exposed to the Holocaust). All participants in the comparison group had low PTS. Psychological distress was measured using the Patient Health Questionnaire-4 (PHQ-4) scale of depressive symptoms and anxiety. Activity engagement was assessed by a four-item scale constructed for the study, which measured the extent to which participants engaged in four activities during the preceding weeks: physical activity, leisure activities, daily planning, and execution of the daily plans.
Drawing on this dataset, Bergman etal., analyzed the distress of HS and the role of activity engagement. They found those survivors not suffering from high-PTS reported psychological distress similar to that of the comparison group. However, high-PTS survivors reported increased psychological distress. An interaction analysis of PTS and activity engagement within the HS group revealed that high-PTS survivors displayed extremely high levels of psychological distress when activity engagement was low but significantly lower levels of distress when activity was high.
This study offers several compelling strengths. First, it uses a timely dataset of those who did and did not experience the Holocaust, collected during a global pandemic in which the lives of older adults were threatened, and they faced restrictions to their freedom, in a manner that could bear some resemblance to Holocaust experiences. Second, this study joins other investigations during COVID-19 which point to the general resilience of older adults in the face of the pandemic (Vahia etal., Reference Vahia, Jeste and Reynolds2020). That is, most participants in the study (80%), both HS and comparisons, did not display high levels of distress in the face of the pandemic. They showed resilience, and this could have helped them deal with the new threat.
The study is also noteworthy for its focus on the vulnerabilities and coping mechanisms of HS. It found that in parallel to their resilience, some HS showed a specific vulnerability related to the psychological effects of the pandemic. The finding suggests that HS with high PTS may be particularly vulnerable to the effects of COVID-19, more so than older adults who did not experience the Holocaust. At the same time, however, a meaningful coping resource emerged: engagement in daily activities and in activity planning. While HS with high PTS were less likely to engage in activities than comparisons (non-HS), those who did engage tended to fare better in terms of psychological distress. This is important information for those working with HS; promoting endeavors such as physical activity or daily planning may mitigate the effects of the Holocaust experience and ensuing PTS on psychological distress during stressful times.
In the remainder of this commentary, I would like to reflect on the implications of these important findings and the questions they raise. The study sheds light on activity engagement – a topic less often explored in relation to HS. Ample research on this population has documented their resilience and vulnerability in relation to mental and physical health (Barel etal., Reference Barel, Van IJzendoorn, Sagi-Schwartz and Bakermans-Kranenburg2010; Shrira etal., Reference Shrira, Palgi, Ben-Ezra and Shmotkin2010). But less attention has been paid to various activities in which HS may engage and which may contribute to their coping (Stesssman etal., Reference Stesssman2008). Activity engagement offers numerous benefits, including mental stimulation, an enjoyable occupation, connection with others, and physical exercise (Cohn-Schwartz, Reference Cohn-Schwartz2020). Future research could build on this important addition to the literature by Bergman etal., and examine more in-depth the contribution of specific activities. For example, the various activities likely exert their effects through different mechanisms and could be related to different outcomes. Particular attention should be brought to bear on the differences and similarities between activity planning and executing the planned activities. While they were lumped together by the Bergman etal. study, they are likely to exert their effects in different ways.
The findings also call for an investigation of additional types of activities among HS. Especially needed is an exploration of the social resources HS have and how these can protect them during current adverse events. Previous research has indicated the protective role of social connections against poor mental and physical health among adults exposed to other adverse events, such as warfare (Schwartz and Shrira, Reference Schwartz and Shrira2019) and natural disasters (Cherry etal., Reference Cherry, Sampson, Nezat, Cacamo, Marks and Galea2015). In the case of HS, there are indications of lower support seeking during the Holocaust (Suedfeld etal., Reference Suedfeld, Krell, Wiebe and Steel1997), although 40 years after the war HS reported a strong emphasis on intimate relationships (Suedfeld etal., Reference Suedfeld, Soriano, McMurtry, Paterson, Weiszbeck and Krell2005). However, it is less known about their social relationships in the present. When looking at the current times, we need to differentiate between social resources available shortly after a recent traumatic event (e.g. during the pandemic) and resources that exist in one’s regular daily lives. Soon after a traumatic event, research often finds that an individual’s social ties mobilize to help him or her cope with the event (Stanko etal., Reference Stanko2015). But what happens later? And how do these processes play out for HS? Some hints in that direction come from a finding that HS with high PTS reported increased loneliness during the COVID-19 pandemic (Maytles etal., Reference Maytles, Frenkel-Yosef and Shrira2021), but it remains an open question whether they were also lonelier before the pandemic and how their social relationships acted during the pandemic in comparison to adults who did not experience the Holocaust.
A final question triggered by Bergman etal. paper is more general. Seventy-six years after the end of the Second World War, the youngest HS are now very old, and as time goes by, fewer survivors will be left with us. We should therefore strive to understand what lessons can be learnt from HS that could aid other adults who are coping with early-life trauma or trauma in general. It should be noted that research on HS already offers many insights into coping with complex traumas and resilience in the face of immense hardships (Bachner etal., Reference Bachner, Carmel and O’Rourke2018; Greene etal., Reference Greene, Hantman, Sharabi and Cohen2012). However, it is possible that more could be done to facilitate such an understanding. For example, in Bergman etal.’s study, the comparison group was composed only of adults with low PTS, thereby making it difficult to discern whether the group differences reflected the effects of the Holocaust itself or PTS in general. As the authors note, additional research is needed to explore these relationships with additional clinical populations. Consequently, future studies should compare HS to other older adults who survived other types of traumas.
As with any study, the findings need to be interpreted within the context of the study’s limitations. First, PTS, activity engagement, and psychological distress were measured at the same time point. Thus, causal inferences cannot be made because the temporal precedence of engaging in more activities prior to reporting lower psychological distress cannot be established. Reverse causality cannot be ruled out, as individuals who are in distress may be less inclined to engage in activities. Furthermore, it is unclear whether the PTS and activity engagement of HS changed in response to the pandemic, or whether these preceded the pandemic. Another limitation is that the authors examined activities as a composite score which does not provide insight into what sort of activities were most protective. The individual components that make up activities in this study, specifically physical activities, leisure activities, and activity planning, are all thought to contribute to coping. Identifying the individual components of activities that are most protective is important and can guide future efforts to increase the resilience of older adults who need to cope with the consequences of old and new adversities.
Nevertheless, the paper by Bergman etal. provides much-needed scientific and policy-relevant insights into the state of HS during the COVID-19 pandemic. The work makes an important contribution to our understanding of the processes of coping and resilience among HS during this global health crisis, and it highlights the need for greater attention to the value of activity engagement and planning. A key practical message for clinicians is the importance of asking HS about their activity engagement and assessing whether and how this could be optimized.
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The COVID-19 pandemic has threatened the health and well-being of older adults around the world, but certain subgroups, such as trauma survivors, could be more affected than others as they may face once again a threat to their health and their lives. Holocaust survivors (HSs) constitute a particularly vulnerable group of trauma survivors since they often report increased posttraumatic symptoms (PTSs) and psychological distress compared to non-HS comparisons. At the same time, however, they display general resilience, which helps them live productive and meaningful lives (Barel etal., Reference Barel, Van IJzendoorn, Sagi-Schwartz and Bakermans-Kranenburg2010; Ohana etal., Reference Ohana, Golander and Barak2014). The COVID-19 pandemic may pose a specific threat to HS, as it could remind them of past traumas from the Holocaust. Recent research has suggested this is the case and highlighted that some HS are more vulnerable in the face of the pandemic, especially those with high PTS (Maytles etal., Reference Maytles, Frenkel-Yosef and Shrira2021) and those who contracted an infectious disease during the Holocaust (Shrira etal., Reference Shrira, Maytles and Frenkel-Yosef2020). Given the vulnerabilities of HS in the pandemic, we should ask which factors promote resilience and improve their coping.
Within this context, Bergman etal. (Reference Bergman, Maytles, Frenkel-Yosef and Shrira2021) have written an important paper on the potential sources of resilience among HS. Specifically, they address the question of whether engaging in activities during the pandemic is related to less psychological distress among HS. Previous research has demonstrated that among trauma-exposed adults, engaging in planful problem-solving activities is associated with reduced distress (Hansen and Ghafoori, Reference Hansen and Ghafoori2017). Furthermore, planful problem solving is a prominent feature in the narratives of survivors both during and after the Holocaust (Suedfeld etal., Reference Suedfeld, Krell, Wiebe and Steel1997). The study by Bergman etal. underlines the importance of activity engagement as a means of coping with external negative events and yields important results in view of future research and practice with vulnerable older populations.
Data for this study were collected from 131 older Jewish Israelis aged 76+ years, between April and June 2020. During this period, COVID-19 restrictions were gradually lifted and were not reintroduced until July 2020. The sample was divided into HS with either high or low PTS and comparisons (not directly exposed to the Holocaust). All participants in the comparison group had low PTS. Psychological distress was measured using the Patient Health Questionnaire-4 (PHQ-4) scale of depressive symptoms and anxiety. Activity engagement was assessed by a four-item scale constructed for the study, which measured the extent to which participants engaged in four activities during the preceding weeks: physical activity, leisure activities, daily planning, and execution of the daily plans.
Drawing on this dataset, Bergman etal., analyzed the distress of HS and the role of activity engagement. They found those survivors not suffering from high-PTS reported psychological distress similar to that of the comparison group. However, high-PTS survivors reported increased psychological distress. An interaction analysis of PTS and activity engagement within the HS group revealed that high-PTS survivors displayed extremely high levels of psychological distress when activity engagement was low but significantly lower levels of distress when activity was high.
This study offers several compelling strengths. First, it uses a timely dataset of those who did and did not experience the Holocaust, collected during a global pandemic in which the lives of older adults were threatened, and they faced restrictions to their freedom, in a manner that could bear some resemblance to Holocaust experiences. Second, this study joins other investigations during COVID-19 which point to the general resilience of older adults in the face of the pandemic (Vahia etal., Reference Vahia, Jeste and Reynolds2020). That is, most participants in the study (80%), both HS and comparisons, did not display high levels of distress in the face of the pandemic. They showed resilience, and this could have helped them deal with the new threat.
The study is also noteworthy for its focus on the vulnerabilities and coping mechanisms of HS. It found that in parallel to their resilience, some HS showed a specific vulnerability related to the psychological effects of the pandemic. The finding suggests that HS with high PTS may be particularly vulnerable to the effects of COVID-19, more so than older adults who did not experience the Holocaust. At the same time, however, a meaningful coping resource emerged: engagement in daily activities and in activity planning. While HS with high PTS were less likely to engage in activities than comparisons (non-HS), those who did engage tended to fare better in terms of psychological distress. This is important information for those working with HS; promoting endeavors such as physical activity or daily planning may mitigate the effects of the Holocaust experience and ensuing PTS on psychological distress during stressful times.
In the remainder of this commentary, I would like to reflect on the implications of these important findings and the questions they raise. The study sheds light on activity engagement – a topic less often explored in relation to HS. Ample research on this population has documented their resilience and vulnerability in relation to mental and physical health (Barel etal., Reference Barel, Van IJzendoorn, Sagi-Schwartz and Bakermans-Kranenburg2010; Shrira etal., Reference Shrira, Palgi, Ben-Ezra and Shmotkin2010). But less attention has been paid to various activities in which HS may engage and which may contribute to their coping (Stesssman etal., Reference Stesssman2008). Activity engagement offers numerous benefits, including mental stimulation, an enjoyable occupation, connection with others, and physical exercise (Cohn-Schwartz, Reference Cohn-Schwartz2020). Future research could build on this important addition to the literature by Bergman etal., and examine more in-depth the contribution of specific activities. For example, the various activities likely exert their effects through different mechanisms and could be related to different outcomes. Particular attention should be brought to bear on the differences and similarities between activity planning and executing the planned activities. While they were lumped together by the Bergman etal. study, they are likely to exert their effects in different ways.
The findings also call for an investigation of additional types of activities among HS. Especially needed is an exploration of the social resources HS have and how these can protect them during current adverse events. Previous research has indicated the protective role of social connections against poor mental and physical health among adults exposed to other adverse events, such as warfare (Schwartz and Shrira, Reference Schwartz and Shrira2019) and natural disasters (Cherry etal., Reference Cherry, Sampson, Nezat, Cacamo, Marks and Galea2015). In the case of HS, there are indications of lower support seeking during the Holocaust (Suedfeld etal., Reference Suedfeld, Krell, Wiebe and Steel1997), although 40 years after the war HS reported a strong emphasis on intimate relationships (Suedfeld etal., Reference Suedfeld, Soriano, McMurtry, Paterson, Weiszbeck and Krell2005). However, it is less known about their social relationships in the present. When looking at the current times, we need to differentiate between social resources available shortly after a recent traumatic event (e.g. during the pandemic) and resources that exist in one’s regular daily lives. Soon after a traumatic event, research often finds that an individual’s social ties mobilize to help him or her cope with the event (Stanko etal., Reference Stanko2015). But what happens later? And how do these processes play out for HS? Some hints in that direction come from a finding that HS with high PTS reported increased loneliness during the COVID-19 pandemic (Maytles etal., Reference Maytles, Frenkel-Yosef and Shrira2021), but it remains an open question whether they were also lonelier before the pandemic and how their social relationships acted during the pandemic in comparison to adults who did not experience the Holocaust.
A final question triggered by Bergman etal. paper is more general. Seventy-six years after the end of the Second World War, the youngest HS are now very old, and as time goes by, fewer survivors will be left with us. We should therefore strive to understand what lessons can be learnt from HS that could aid other adults who are coping with early-life trauma or trauma in general. It should be noted that research on HS already offers many insights into coping with complex traumas and resilience in the face of immense hardships (Bachner etal., Reference Bachner, Carmel and O’Rourke2018; Greene etal., Reference Greene, Hantman, Sharabi and Cohen2012). However, it is possible that more could be done to facilitate such an understanding. For example, in Bergman etal.’s study, the comparison group was composed only of adults with low PTS, thereby making it difficult to discern whether the group differences reflected the effects of the Holocaust itself or PTS in general. As the authors note, additional research is needed to explore these relationships with additional clinical populations. Consequently, future studies should compare HS to other older adults who survived other types of traumas.
As with any study, the findings need to be interpreted within the context of the study’s limitations. First, PTS, activity engagement, and psychological distress were measured at the same time point. Thus, causal inferences cannot be made because the temporal precedence of engaging in more activities prior to reporting lower psychological distress cannot be established. Reverse causality cannot be ruled out, as individuals who are in distress may be less inclined to engage in activities. Furthermore, it is unclear whether the PTS and activity engagement of HS changed in response to the pandemic, or whether these preceded the pandemic. Another limitation is that the authors examined activities as a composite score which does not provide insight into what sort of activities were most protective. The individual components that make up activities in this study, specifically physical activities, leisure activities, and activity planning, are all thought to contribute to coping. Identifying the individual components of activities that are most protective is important and can guide future efforts to increase the resilience of older adults who need to cope with the consequences of old and new adversities.
Nevertheless, the paper by Bergman etal. provides much-needed scientific and policy-relevant insights into the state of HS during the COVID-19 pandemic. The work makes an important contribution to our understanding of the processes of coping and resilience among HS during this global health crisis, and it highlights the need for greater attention to the value of activity engagement and planning. A key practical message for clinicians is the importance of asking HS about their activity engagement and assessing whether and how this could be optimized.