About The Project

SUMMARY OF PHASE I

Videotestimony Study of Chronically Hospitalized

Holocaust Survivors in Psychiatric Institutions in Israel

--Phase I--

The Creation of Videotestimonies of Holocaust Survivors in Psychiatric Institutions in Israel

Twenty-six videotestimonies from psychiatrically-hospitalized Holocaust survivors in Israel have been obtained, following the research protocol approved by Yale University, Beer Yaakov, and Lev Hasharon. After extensive telephone discussions, Dr. Laub visited the two hospitals on July 3rd and 4th, 2002 in order to finalize agreements. A start date for the videotestimonies was set for October 2002.

The subjects were drawn from the approximately 100 residents housed in the hostel for Holocaust survivors established in 2000 at the Beer Yaakov Mental Health Center and from the approximately 100 residents housed in the hostel at Lev Hasharon Mental Health Center. Before these hostels were established, the survivors spent many years in Israeli psychiatric hospitals. This survivor population has an age range of 57 - 97 years and has severe, chronic mental illness. From among those suitable for the study, subjects were chosen after screening the patient files to see which survivors meet the inclusion and exclusion criteria of the study, and after obtaining informed consent from the subject and guardian as necessary. We sought the patients with highest and most stable functioning, whose clinical course is least likely to spontaneously change during the course of the study. The inclusion and exclusion criteria were as follows:

Inclusion criteria: victims of Nazi persecution as defined by the Conference on Jewish Claims Against Germany, Inc. (in hiding, ghettos, concentration labor and death camps, etc.), who were at least 3 years old during the time of persecution, and are willing and capable of telling a story, even if only in fragments.

Exclusion criteria: survivors with severe cognitive impairments such as Alzheimer’s disease or other forms of dementia, mutedness, an inability or unwillingness for interpersonal communication, or severe psychotic disorganization that precludes any coherence to a video testimony.

The subjects were recruited by Dr. Mordechai Weiss (clinical co-PI and deputy director of the Beer Yaakov Mental Health Center) and Dr. Boris Finkel (director of the Holocaust Survivors Unit at Lev Hasharon).

The 26 subjects were grouped into thirteen matched pairs randomly assigned to be either experimental or control subjects. Pairs were being matched according to the subjects’ present mental state (including current forms of experiencing trauma such as paranoia, profound depression, nightmares, experiences of panic or withdrawal), ability to cooperate, and ability to organize their narratives. One member of each pair was randomly designated as experimental (receiving videotestimony intervention in October-November 2002), the other as control (receiving videotestimony intervention after crossover in April 2003).

All participants underwent initial psychiatric and psychological evaluations, using instruments specific for PTSD with psychosis, in an attempt to diagnostically differentiate it from other psychoses like schizophrenia. Measures included the Structured Interview for Disorders of Extreme Stress (SIDES),11 PTSD symptom scale,12 Clinician-Administered PTSD Scale, Form 2, (CAPS-2),13 the Positive and Negative Syndrome Scale (PANSS),14 the Mini-Mental State Examination (MMSE),15 the Clinical Global Impression (CGI) scale, and the Rorschach test.

On October 28, 2002, Dr. Irit Felsen (an Israeli psychologist who has worked extensively with Holocaust survivors and their children) and Dr.Dori Laub, started the interviewing process for the experimental group in both Beer Yaakov and Lev Hasharon hospitals after the psychological and psychiatric testing had been completed. Fourteen testimonies were obtained between October 22nd and November 3rd (10 patients were from Beer Yaakov and 4 from Lev-Hasharon); each lasting between 1 to 2 hours. Planning meetings, summary meetings, as well as meetings with the staff also took place throughout this period, in order to report findings regarding the patients who had the videotestimony intervention (the experimental group).

Extensive telephone consultations took place to learn from the first part (pre-crossover) and prepare for the second, which was planned for the end of March 2003, but had to be postponed to the end of April because of the war in Iraq. The second part of the project (psychological evaluation and psychiatric testing of both the experimental and control groups, followed by videotestimony and intervention for the control group) started on April 22, 2003 and lasted until May 2, 2003. During this period of time, 12 patients from the control group were interviewed and their testimony videotaped. (Two patients withdrew their consent at the last moment, so our control group included 12 and not 14 patients as originally planned.) All together, 26 testimonies have been obtained, 14 experimental and 12 in the control group. Eight testimonies were obtained in Lev Hasharon (4 in the experimental and 4 in the control group) and 18 testimonies were obtained in Beer-Yaakov; (10 testimonies in the experimental and 8 testimonies in the control group). A final round of psychological and psychiatric testing was carried out on the control group four months after videotestimony. Data and safety reviews were performed after the second and third rounds of evaluation and testing.

Interviews with patients were always conducted by two interviewers and while Dr. Laub participated in every interview, the co-interviewers changed. In the first group, at the end of October, Dr. Laub and Dr. Felsen were the main interviewers and staff members from Beer-Yaakov supplemented the team. In the second round of interviews, Dr. Laub was the main interviewer and the staff of Beer-Yakov Hospital supplemented the group. Twenty-two of the videotestimonies have been transcribed and translated into English for further in-depth analysis.

The staff at Beer Yaakov Hospital began viewing the testimonies and including them in their treatment planning. Viewings of the testimonies started spontaneously after the first group of videotapes were finished. In the summer of 2002, a pilot seminar which lasted for about three months, was started with Miriam Rieck (study coordinator) attending in order to view testimonies and train staff as to their use in the treatment of the survivors. A part-time occupational therapist was hired for the specific purpose of working with the survivors who participated in the study. The videotestimony project funded her employment until 2005.

With funds transferred from the Claims Conference grant, the Lev Hasharon Hospital set up a parallel individualized follow-up treatment program for the patients who participated in the video testimony project.

A summary conference to review initial findings and possible complications for the treatment of survivors was held December 8, 2003 primarily for the staff of the hospitals that were involved. This was an in-service training to improve the treatment skills of staff who worked with survivor populations in the hospitals. A second training retreat for the staff of both hospitals was held on June 16-17, 2004 in Maaleh Hachamisha, Israel. The second day was open to mental health professionals from Israel who work with Holocaust survivors.

RESULTS
Preliminary results indicated 38% of patients meeting criteria for PTSD at the first interview and only 19% at the second interview. There was a significant reduction of functional impairment as well as symptom severity and intensity of all posttraumatic clusters (intrusion, avoidance and hyper arousal) with “avoidance” showing most reduction. Ten subjects indicated an improvement of 30% or more in total posttraumatic severity score. No difference in PANSS, MMSE, SIDES and CGI total scores were noted post-interview or between the 2 pre-interview evaluation batteries in the control group. Prior to and post-video testimony interviews female subjects showed higher prevalence of PTSD symptomatology. There was an inverse correlation between total CAPS-2 scores and total PANSS scores both at baseline and at follow-up. The Rorschach indicates that issues regarding severe and extreme trauma experienced many years previously may still be expressed in a profound manner in Rorschach testing and which may be affected by therapeutic interview years after the acute event. A retest of all the participants in the study is planned to examine if the improvement held up four years after its completion in the spring of 2007.

CONCLUSION
Study observations indicate the clinical benefits of the testimony interview in the alleviation of many post-traumatic symptoms, but not psychosis, in a cohort of psychiatrically ill Holocaust survivors despite the lapse of up to 60 years since the traumatic event and suggest implications for the care and rehabilitation of such a patient subpopulation.

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SUMMARY OF PHASE II

Videotestimony Study of Chronically Hospitalized

Holocaust Survivors in Psychiatric Institutions in Israel

--Phase II--

An Interdisciplinary In-depth Analysis of the Videotestimonies Obtained in Phase I

Theoretical Considerations

This is the first in depth study ever conducted with a group of severely traumatized patients who had been chronically hospitalized in psychiatric facilities. The application of extensive psychiatric and psychological testing, of the videotestimony intervention, of qualitative interdisciplinary evaluation and formulation and of content analysis is also most likely a first time occurrence in this population. Psychoanalytic theory and psychoanalytic listening are the bedrock from which both the research questions will be adapted and research methodologies shall flow. The significance of this study lies not only in developing, adapting and testing new methodologies but also in the scientific and clinical questions it addresses such as the relation between trauma and psychosis, the differential diagnosis between traumatic psychosis and schizophrenia and the efficacy of videotestimonies as a treatment intervention.

Phase II

Phase II of this study will move beyond the traditional clinical and psychiatric research perspectives in an attempt to widen the scope of the entire project by opening the clinical study of Phase I to other disciplines, such as social sciences and cultural studies. We postulate (drawing again on psychoanalytic theory) that the major historical cataclysmic events of the twentieth century (World War, Genocide) create a tear in the social link between people (Davoine / Gaudillière) – on an intra-psychic, familial, communal and societal level. This tear is so fundamental that it precludes its own representation, through processes of symbolization, speech and narrative formation, which are predicated on the intactness of the social link and on the intra- and interpersonal dialogue the social link engenders. As a consequence of massive historical trauma representation is replaced by erasure, by an absence of experience and of narrative, and ultimately by silence. As we look in the Holocaust survivors who participated in this study, at the most severe (living) psychological casualties of genocide, the question arises whether they represent the ultimate in such erasure of experience and narrative, the extreme on the spectrum of speechlessness and silence. To asses the extent and evaluate the specific nature of such erasure, to grasp its phenomenology and detect the behaviors in which it manifests itself in the audiovisual texts of the testimonies, experts from disciplines other then psychiatry will be brought in to create research perspectives and to apply methodologies from their respective disciplines, best suited to describe and measure these phenomena.

Research Methodology

The research modus of Phase II will be interdisciplinary, drawing on a variety of content analysis techniques developed in the fields of psychoanalysis, social science and cultural studies. The project will likely draw on several sub-disciplines such as speech pathology, linguistics and media analysis. It will include an analysis of the non-verbal communication of the interviewees. What follows is the description of several studies already underway or in their planning stage.

Since September 2006, a group of German psychoanalysts affiliated with the Sigmund Freud Institut (Frankfurt a.M.) and Kassel University- Drs. Marianne Leuzinger, Andreas Hamburger and Werner Bohleber, have been working on developing a clinical conceptual research model for the study of the phenomenology of traumatic psychosis that can be applied to the video testimonies of the chronically hospitalized Holocaust survivors. The next meeting of the work took place on March 9-11, 2007 in Frankfurt a.M. Germany.

Through the participation of the Sigmund Freud Institut and of Kassel University, a systematic analysis of the video testimonies obtained in Phase I, based on a psychoanalytic group rating design, will be accomplished. We will address the question: How do trauma and psychosis interrelate 1) in the context of the traumatically inhibited processes of narrativization of life histories and 2) in the transference distortion of the diagnostic- therapeutic relationship created in the testimony. This research is aimed to shed light as well on the problem of the origination of the traumatic psychosis and that of the chronicity of its endurance.

An accompanying meta-analytic literature research will lead to the formulation of a comparative research design that will include a control group in Israel composed of chronically hospitalized psychotic patients who are not Holocaust survivors. All the empirical research instruments applied to the interviews in Phase I as well as the above mentioned psychoanalytic group rating design will be applied to the control group subjects as well, so as to make a scientifically valid comparison possible.

Furthermore, to provide an additional context, historic research will be done on the individual and social context of the relocation of psychotic patients in the years 1948-1955 from Germany to Israel. The combined research results will lead to a tentative re-narrativization of the denied and de-narrativized life histories of the chronically psychotic Holocaust survivors and to an empiric as well as qualitative description of the traumatic psychosis as a nosological category.

In a separate project, analysis of content and of affect regulation using Glaser’s grounded theory is currently being applied by psychoanalyst Suzanne Kaplan, Ph.D. of Stockholm University to the study of a number of video testimonies which have been transcribed and translated into English. Dr. Kaplan has started her work in the project in January 2006. Glaser’s grounded theory offers a theoretical framework allowing an analysis of data, which is not guided by preconceived hypotheses but which, on the contrary, generates hypotheses and eventually concepts in its process. Some of the research variables to be considered in the content analysis of the video testimonies are the use of silence (including duration, positioning, and intent of silence), the use of nonverbal communication (gesticulations as meaning), the use of space, and the construction of narrative (use of first/third person for emotional distancing, active or passive verbs, attempts at “objectification” etc.). Glaser’s grounded theory method can generate quantitative data to be analyzed further in statistical and graphical reports to demonstrate a variety of patterns and relationships. In addition, it can produce qualitative results, which can be examined further for patterns and relationships. Content analysis of the narratives may help to discern a “key moment,” that is, a moment of awareness where the narrative is “unlocked.”

A third approach, already underway (Robin Kowalski, PhD, Clemson University, Clemson, S.C., U.S.A.) is conducting a linguistic analysis of the video testimony narratives by using Jannie Pennebaker’s Linguistic Inquiry and Word Count Strategy (LIWC 2001). The LIWC analyses the affective, cognitive and structural elements of written text on a word by word basis; Kowalski in her study is applying LIWC to examine differences in structure and affect accompanying the narratives of the chronically hospitalized patient group and of a control group, i.e. video testimonies of non-psychotic Holocaust survivors.