Long-term legacies of war: An outline of a study among a Post World War II generation of clients receiving psychotherapeutic treatment in Foundation Centrum '45, the Netherlands

Introduction

“Camp is not so much a place as a condition. “I’ve had camp,” he says. That makes him different from us. We’ve had chicken pox and German measles. And after Simon fell out of a tree, he got concussion and he had to stay in bed for weeks. But we never had camp.“

- Nightfather, Carl Friedman; novel about a man’s experiences in the Nazi concentration camps as seen through the eyes of his children -

Both clinical observations and research studies have consistently demonstrated that survivors of extreme, prolonged stress are susceptible to enduring physical and psychological impairment. Consequently, a mental disorder or chronic physical illness in one or both parents is likely to adversely affect the spouse and children. War negatively impacts the previously functional coping mechanisms within families and society.

Many studies have been published on the transmission of trauma from - Holocaust -survivors to their children (Kellermann, 2000). While many clinicians tend to generalize their findings to apply to most children of war survivors, most empirical research could not substantiate the claim that there was more psychopathology in children of survivors than in comparable populations (e.g., Van der Velden, 1999; Van IJzendoorn et al, 2003). However, there appears to be sufficient evidence that children of trauma survivors constitute a high-risk group for mental disturbances (Baider et al, 2006; Solomon, 1988; Yehuda, 2006).

The ability of children to deal with their parents' psychological burden depends on many factors. There is considerable evidence that parental psychological disorder increases the risk of disturbance in child development and poor mental health in adulthood, although many of the children also show resilience.

The scientific attention for people belonging to the post-war generation has decreased dramatically during last years. Besides, it has been mainly focused on the children of Holocaust survivors. At the same time, the number of postwar generation clients applying for help has been consistently large. Unfortunately, current warfare is increasing the number of affected families around the world daily. Therefore, the scientific study of children in families with a traumatized member is important for the future, not only with regard to intervention but with regard to prevention in particular.

Foundation Centrum '45 is a Dutch nationwide mental health institute for research and treatment of mental complaints related to traumatic experiences. Foundation Centrum '45 has gained extensive experience in working with war-stricken people and their offspring, among them veterans, refugees and victims of torture. During the last two decades, a consistently large proportion of all clients of Foundation Centrum '45 has belonged to the WWII post-war generation.

As part of the international project (ACET: Providing and enhancing rehabilitation services for second generation victims of torture and war) we have systematically analysed data concerning the characteristics of and the interventions offered to the post-war generation clients within Foundation Centrum '45. We have tried to gain insight into the progress of complaints and symptoms related to the treatment of this group. More specific questions were:

•    With what kind of problems are these clients being referred to our institute,

•    What are the characteristics of families of origin,

•    How do these clients experience treatment?

This text is a contribution to the final report of the ACET project. First, we describe the methodology that has been chosen and that consists of roughly three parts: analysis of medical files, focus group discussions with teams and client-groups and analysis of questionnaires (part of routine outcome monitoring within Foundation Centrum '45). Secondly, we describe the outcomes of these steps. Finally, we discuss the outcomes and come to conclusions and recommendations.

The outcomes and implications of this study are being discussed with both clients and members of the treatment team within Foundation Centrum '45. Furthermore, they have been presented at an international conference and they will be described in (two) international papers.

Methods

Participants

This study involved the post-war generation that belongs to the client population within Foundation Centrum '45. Participants were clients who are born after the liberation - in the Netherlands after May 5th, 1945 or in the Former Dutch East Indies after August 15th, 1945 -, of whom one or both parents have been traumatized by the German or Japanese occupation. The participants themselves did therefore not have experienced World War II themselves, although in the Dutch East Indies a liberation war (1945-1949) took place after the Japanese surrendered.

Procedure

Firstly, 400 medical files have been examined. Information from intake records was systematically collected using a codebook that was developed for the purpose of the study. Information was gathered on themes that were regarded relevant for the study (war experiences by parents, complaints and symptoms, diagnoses according tot the DSM-III-R/DSM-IV (APA, 1994, 2000). This information was to some extent subjective because the wording was by the clinician who had performed the first clinical interview (intake). Secondly, to gain more insight in the kind of and experiences with treatment, focus-group discussions were held, with both clients - who were in therapy at that moment - (3, N=23) and the treatment team (1, N=10). During these meetings, the main themes of treatment were discussed. Only two post-war generation clients rejected participation: one because he had only one week of therapy and the other because he found it difficult to express himself on this subject.

Thirdly, 498 standard assessments (using screening questionnaires for general psychological symptoms and posttraumatic stress symptoms)) have been analyzed. These data have been gathered systematically in the period 2001-2008. Throughout the years, some of these measures have been applied twice: once at intake and after closure of the therapy as well (exit). Both intake- and exit-assessments have been available of 131 clients. Furthermore, a restricted number of clients completed a screening questionnaire for personality problems (VKP see instruments). The VKP was added to the standard test battery more recently, therefore not available for all clients. Clients completed this questionnaire directly after the intake process, before the start of treatment.

Instruments

Coding-schedule for medical files

A coding scheme for the analysis of medical files was developed. The inter-rater reliability was tested and found acceptable (r=0.78). The information that was obtained by studying

the medical files was of course based on the descriptions and judgments of clinicians and therefore “second-hand”. Information was coded on the next themes: demographic characteristics, diagnosis, complaints and problems and characteristics of family of origin.

Questionnaire for characteristics of personality (VKP)

The VKP (‘Vragenlijst voor Kenmerken van de Persoonlijkheid’) is a Dutch selfreport instrument for the screening of personality disorders and symptoms. It can be used within both systems: the DSM and ICD classification systems. The VKP consists of 182 items divided into 7 thematic areas. Responses to the individual items refer to the previous 5 years.

An internal consistency of 0.66 for DSM-III-R and 0.64 for ICD-10 has been reported (Duijsens, Eurelings-Bontekoe, & Diekstra, 1996). It should be taken into account that the VKP is found to overestimate the occurrence of personality disorders.

Symptom Checklist-90 (SCL-90)

The SCL-90 is a 90-item self-report system inventory scored on a 5-point rating scale. This instrument, developed by Derogatis, Lipman and Covi (1973), is designed to reflect the psychological symptom patterns of community, medical and psychiatric respondents. The SCL-90 is also useful in measuring patient progress or treatment outcomes. It is divided into ten subscales, containing eight dimensions of psychiatric symptomatology: 1. anxiety, 2. agoraphobia, 3. depression, 4.somatization, 5. obsessive-compulsiveness 6. paranoid ideation and interpersonal sensitivity, 7. hostility and 8. sleeping problems. In many studies the psychometric properties of the questionnaire were good (Arrindell & Ettema, 2003).

Self-report scale for PTSD (ZIL)

The ZIL (‘Zelf Inventarisatie Lijst Posttraumatische Stressstoornis’) is a Dutch selfreport questionnaire measuring posttraumatic stress symptoms. It consists of 22 questions that are scored on a 4-point rating scale. This instrument checks the Post Traumatic Stress Disorder (PTSD) symptoms according to the DSM-IV. The questionnaire provides a total score of posttraumatic stress symptoms, but can also be used to calculate separate scores for the three clusters, which are: 1. intrusion (e.g., flashbacks - reliving the trauma over and over, including physical symptoms like a racing heart or sweating - and bad dreams)

2. avoidance (e.g., feeling emotionally numb and having trouble remembering the dangerous event) and 3. hyperarousal (e.g., being easily startled and having difficulty sleeping). The psychometric properties of the questionnaire are satisfactory (Hovens, Bramsen, & Ploeg, 2000).

Statistical analyses

The information from medical files was coded and statistically analysed by using descriptive procedures mostly. For the analyses of intake- and exit assessments, we used an independent-samples t test to make comparisons in mean scores between the post-war generation and control group. Further, we used a paired-samples t test to make comparisons of intake- and exit outcomes. To compare the percentage scores on the VKP between the post-war generation and the control group, we used a z- test (2-tailed).

For the statistical computations we used the Statistical Package for Social Sciences (version 15, SPSS inc.). For the analysis of the focus group discussions we chose a qualitative procedure by categorizing segments of the texts.

Results

In this section, the main outcomes of the study with regard to the three research questions will be described.

(1) Demographic characteristics

In general, more women than men applied for help in our institute. Most of the post-war clients have been born within the first two decades after the war (WWII) and they have an average age of 52 years. Furthermore, many of them have high educational level.

Table 1: Demographic characteristics

(2) Medical files

Diagnosis

Firstly, we categorized the diagnoses according the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, APA, 2000). At axis I - primary symptomatology - post-war generation clients were mostly diagnosed with mood (45.8%) disorders and anxiety (31.5%) related disorders. At intake, clinicians were likely to postpone diagnoses at Axes II - personality disorders - (65,5%). In only 3,5% of these clients a personality related disorder was observed to be clearly non-present.

Complaints and problems

Secondly, we examined and summarized the problems and complaints that had been reported at intake. In many reports relational problems are being mentioned (68%). These concern not only relational problems with partners, but also problems in the relationships with parents and own children are being noted frequently.

Almost 60% of the post-war generation clients have problems regulating aggression. Some have difficulties to control their aggressive impulses; while others can not express their aggressive feelings. Among many clients a feeling of low self-esteem is present (58,3%). Problems with autonomy and difficulties with separation are being reported frequently (55,3%). Feelings of guilt and shame in the face of parents, distrust, parentification, problems with attachment and intimacy, perfectionism and fear of failure have been described more often in these reports.

Characteristics of family of origin

In the intake-reports characteristics of the family of origin are being given. Both fathers (83%) and mothers (60%) have been traumatized by the war. (Traumatized or not depended on parents' war experiences and some parents' behaviour possibly related to PTSD symptoms, described in intake reports). A substantial number of clients (52%) have parents that have been traumatized. 52% of the fathers had been detained in a labour camp during the war and 42% of the mothers had been interned in a camp.

In most of the families the war was not (or in rare occasion) talked about. In some of the families (10%), on the contrary, they talked about the war frequently. Few families communicated about the war once in a while (1,5%). Possibly, symptoms of the post-war clients were related to the extent and the way parents communicated about their experiences during the war. Even when the parents seldom spoke about their experiences it may have contributed to increased difficulties among the children. This may be related to a preoccupation on the part of the child with fantasies about what parents experienced. Therefore, not talking about the war may have had a negative effect on these children. According to intake-reports, 74% of these clients have been emotionally neglected and more than a third (36%) were physically abused by one or two parents.

(3) Results focus-group discussions

Description of interventions

Clients from the post-war generation were offered a weekly day-treatment in Foundation Centrum '45 (besides in-patient and ambulatory services). Treatment is multi-disciplinary with psychotherapy, sociotherapy, psychomotor therapy, art therapy and pharmaceutical and social services. In general, treatment lasts one and a half year approximately. The content is based on an integration of perspectives from attachment theory, cognitive

behavioural theory and group-processes. Working with a group provides members with recognition and acknowledgement of past experiences and shared history and is at the same time intended to be a safe place to practice with new behaviour.

During focus-group discussions it was clear that clients understand and are able to explain the intent of treatment. Clients and team-members labelled characteristics of treatment similarly. The professionals mentioned that post-war clients are capable to work on different themes in distinctive therapy modes. The identification with the group post-war clients was significant for the clients. It provides them with recognition and through that with attachment. The focus on the identity development and independency, the focus on the family of origin and the detachment from parents are topics that are characteristic for working with post-war generation, according to team-members.

According to the clients themselves, the issues that are significant in treatment are: Discovery of own identity, awareness of own feelings, clarification and expression of own thoughts, the interrelatedness of feelings and thoughts, sharing thoughts and experiences with other people and exercising difficult or new behaviour in a safe surrounding.

Group treatment

Many clients revealed that the group-focused treatment provided them with a sense of attachment. They referred to the group as their family, a safe haven or a warm bath. During the meetings with clients it was mentioned repeatedly that the group offers recognition and a challenge to try out new behaviour. Not only the therapist, but also group members give useful feedback.

Multidisciplinary work

Almost all clients reported that they appreciated the work in multidisciplinary teams. Not only thinking and understanding, moreover feeling and doing get the attention that is needed. Clients describe the multidisciplinary work as method to gain learning experiences in different modes. The collaboration between team-members is being evaluated very positively by clients. Because of this, clients feel they are being ‘seen’ (respected).

Critical remarks and suggestions

According to a number of clients not everything could be discussed in a group. For a part, individual contacts are being missed. Several clients criticized the number of changes in the groups. These caused many introductions and farewell rituals that took time and may have interrupted treatment processes. Also brought forward were unclearities in procedures, for instance related to treatment evaluations, role of mentor or the scope of possible interventions.

Team-members reported that, in general, the treatment duration was rather long. Too little attention was being paid to rehabilitation in society. Societal reality could be put to the fore, more than it happens now. Thematic working (e.g., during sociotherapy) was being missed by both therapists and clients. This would offer the clients the opportunity to work on a particular issue for a couple of weeks in a row for instance (the social skills training is an example). Both clients and team-members expressed their need for more non-verbal therapies.

(4) Results intake and exit assessments

Questionnaire for characteristics of personality (VKP)

According to the VKP 76,9% of this sample of clients met the criteria of at least one of the personality disorders. Table 2 describes the occurrence of many personality problems among the post-war generation clients. They met the criteria of an Obsessive-compulsive personality disorder and an Avoidant personality disorder in particular. The Obsessive-compulsive disorder is being characterized by psychological rigidity, perfectionism and excessive preciseness. The Avoidant personality disorder is being characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction.

Table 2: Percentage of personality disorders according to the VKP found in the post-war generation group compared with the 'normal population' and patients.

* Significant differences compared with thepost-wargeneration at the confidence level of90%

Symptom Checklist-90 (SCL-90)

In Figure 1 the average intake and exit scores of post-war generation clients on the subscales of the SCL-90 are being depicted. The outcomes of post-war generation clients were compared to the average scores of the criterion group (Arrindell & Ettema 2003). As scores are higher, complaints increase. The post-war generation clients reported many complaints at intake - scores were significantly higher than those of controls (p< .001). Sub-scale scores of clients have decreased significantly (p<.001) at the end of treatment (exit assessment). The scores were still above the average scores of control groups however.

Figure 1: The average intake and exit scores of post-war generation clients on the sub-scales and total scale of the SCL-90 and the average scores of the criterion group.

Self-report scale for PTSD (ZIL)

Figure 2 reflects the average outcomes of pretreatment and posttreatment assessments of the post-war generation clients. These scores were compared to a norm group (Hovens et al., 2000). The higher the score, the more symptoms clients report. From picture 2 it can be derived that the post-war generation suffered from more posttraumatic stress symptoms than the general population (significant higher scores on all sub-scales (p< .001)). Posttraumatic stress symptoms, furthermore, significantly (p< ,001) decreased during treatment. As on the SCL-90, the average scores were still somewhat higher than outcomes of controls.

Figure 2: The average intake and exit scores of post-war generation clients on the sub-scales and total scale of the ZIL and the average scores of the criterion group.

Discussion

This paper described a study conducted on the characteristics of an increasingly neglected generation of the population after war has ended: the children of traumatized parents. Furthermore, the study aimed to shed light on the results of psycho-social treatment within Foundation Centrum '45, the Netherlands.

Outcomes of the study reveal first of all, that it concerns a group of clients with severe negative parenting experiences in their youth and past. Growing up in the post war years and being raised by survivors of war and migration, exposed many of them to an abusive, neglectful and/or fearful climate. Consequently, according to the findings, they developed in a sensitive, fearful way. At the time they applied for help, many suffered from complaints that were related to their autonomy, identity, relations with others, affect-regulation. In particular, problems related to their personality and personality disorders were prevalent. More specific, the Obsessive Compulsive Disorder and Avoidant Personality Disorder were most present.

Several restraints could be mentioned in evaluating this study. One important issue is the retrospective design of the study. Longitudinal, follow-up studies are needed to accurately study the mechanisms of traumatized family dynamics. Young children should be followed up. Further, this study did not include a control group. Therefore no conclusions can be drawn with regard to the why and how of offered interventions. It would be interesting to compare the context specific treatment in Foundation Centrum '45 with a personality focused treatment in other sections of mental health services.

The comparison of intake and exit assessments revealed significant decrease of complaints. The interventions offered are therefore helpful in alleviating the distress. Clients themselves appreciated the group-oriented procedures although at times, some claimed to need an individual approach at times. They felt acknowledged within Foundation Centrum '45 as having been part of a generation growing up in the shadow of the war. The fact that historical knowledge about the Second World War is present and matters in therapy, is important to them. This distinguishes Foundation Centrum '45 from other mental health services.

Conclusion

We may conclude that the post-war generation clients have been raised in families in adverse circumstances. Complaints and symptoms of the post-war generation were mostly associated with chronic problems, difficulties with affect regulation and resulting in problems with identity and personality development. Most members of the post-war generation (clients) have not learned to communicate about their own emotions and own needs.

On the basis of the pretherapy and post therapy assessments, it can be concluded that these clients suffered from a large number of problems that in the course of therapy decreased significantly. Despite this prominent decrease, these clients still had more complaints than controls at the closure of treatment. They remained vulnerable to some extent.

Next, we may conclude that the offered treatment has been evaluated positively by this group of clients. The multidisciplinary approach was regarded as an asset. Clients were well capable of maintaining focus on their particular issues, while team-members collaborated well between distinguished disciplines. The group setting provided opportunities for expressing feelings and verbalizing experiences. The group offered a sense of collectivity and community that is necessary to permit expression of intense emotions. Taking into consideration the relatively long duration of therapy, the question was raised whether a more efficient treatment is possible.

Post-war generation clients in Foundation Centrum '45 felt acknowledged by the WWII-specific context of trauma treatment. They appreciated the familiarity with the socio-historical-cultural backgrounds of war and migration and the social contact with fellow-clients with whom they shared this.

Recommendations

Based on the outcomes of our study among the post war generation clients that visited Foundation Centrum '45, we recommend:

1.    to increase awareness among scientists, policy makers and societies in general to pay attention to the (mental health of the) offspring of victims of war, disaster and violence;

2.    to study empirically and scientifically the consequences of disruptive events in the short and longer term of coping mechanisms within families and systems;

3.    to develop preventive strategies within families when helping individuals, families and broader systems within societies to overcome the negative consequences of large scale disasters and wars;

4.    to apply a combination of cultural and historical knowledge and multidisciplinary approach to psychotherapy in developing mental health services to those who in the aftermath of extremely stressful events need it;

5.    to continue and expand exchange within and across societies and countries within the European Union on this subject. And involve multiple disciplines as well as multiple generations of professionals working in the (mental) health services (e.g., organise summer-school, write curricula for universities and schools, publish articles and have them available in different languages).

References

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C.: Author.

Arrindell, WA. & Ettema, J.H.M. (2003). SCL-90: herziene handleiding bij een multidimensionelepsychopathologie indicator. [SCL-90: revised guide of a multidimensional psychopathology indicator]. Lisse: Swets & Zeitlinger.

Baider L, Goldzweig G, Ever-Hadani P Peretz T. (2006). Psychological distress and coping in breast cancer patients and healthy women whose parents survived the Holocaust. Psychooncology; 15, 635-646.

Duijsens, I.J. (1996). VKP, Assessment of personality disorders: Construction, reliability and validity of the VKP self-report (dissertation). Lisse: Swets & Zeitlinger.

Friedman, Carl. (1994). Nightfather. New York: Persea Books.

Hovens, J. E., Bramsen, I., & Van der Ploeg, H. M. (2000). Zelfinventarisatielijst Posttraumatische Stressstoornis: ZIL handleiding. [Self-inventory scale Posttraumatic Stress Disorder]. Lisse: Swets & Zeitlinger.

Kellermann, N.PF. (2000). Second generation bibliography. Jerusalem: Amcha.

Levav, I., Levinson, D., Radomislensky, I., Shemesh, A, & Kohn, R. (2007).

Psychopathology and other health dimensions among the offspring of Holocaust survivors: Results from the Israel National Health Survey. Israel Journal of Psychiatry; 44, 144-151.

Solomon Z, Kotler M, Mikulincer M. (1988). Combat-related post-traumatic stress disorder among second generation Holocaust survivors: Preliminary findings. Am J Psychiatry;

145, 865-868.

Velden, EG. van der (1999). Getroffen ouders, getroffen kinderen? Een vergelijkende psychologische studie naar de gezondheid en opvoeding van volwassen kinderen van Indische oorlogsgetroffenen. Universiteit Utrecht, academisch proefschrift.

Van IJzendoorn, M.H., Bakermans-Kranenburg, M.J. & Sagi-Schwartz, A. (2003). Are children of Holocaust survivors less well-adapted? A meta-analytic investigation of secondary traumatization. Journal of Traumatic Stress, 16, 459-469

Appendix

An illustration in which a client not only clarified her position within her family, but that also represents the positive effects of the treatment.

During art therapy clients have to portray themes, for example their family. This picture illustrates a sculpture that a post-war generation client completed during art therapy, with the following story:

"Mother was perceived as cold and insensitive; 'not humane' - as a result the client did chose a white tower and not a human form to shape her (seepicture). Father was memorized as being a brave man during the war; he was perceived as being a hero. He was presented as standing on a pedestal with crown and throne. The client herself did not feel she was having an own identity; she felt as if she was an object to her parents. She always had to do what they told her, she was not taught to choose for herself. She represented herself as a pawn. Furthermore, she was isolated by a wall around her. However, as opposed to earlier in her life, the pawn can be moved - it no longer stands fixed to the ground. This may be interpreted as a sign that she can disconnect herself from her family. Nowadays she can run off, to see the full world."

Acknowledgements

This study has been financially supported by a grant of the European Union. Furthermore, the study would not have been possible without the participation of clients and team members. Finally we acknowledge the support of Wim Kleijn and Twan Driessen.

We appreciate the permission to use the image of the sculpture of one of the clients, as well as our cooperation with Chris Wilms, art therapist.

Long-term legacies of war

An outline of a study among a Post World War II generation of clients receiving psychotherapeutic treatment in Foundation Centrum '45, the Netherlands

Marieke Sleijpen MSc, Dr. Trudy Mooren en Prof.dr. Rolf Kleber

© 2009 Stichting Centrum '45

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