This month's column provides an account from Ephraim Reichenberg, who was a prisoner at Auschwitz-Birkenau in 1944, and assessment notes from his clinicians.
I had just turned 17 when my family and I were deported from our Hungarian ghetto on July 7, 1944. Three days later, after a frightening journey which I shared with 70 to 80 people in a sealed livestock wagon, we arrived at Auschwitz-Birkenau. After being herded from the train, we joined the crowd prior to being selected for either the line of people who were destined immediately for the gas chambers or the line of those who were considered fit for hard labor. In the midst of the confusion, terror, and disorder, I heard “Zwillinge raus” (“twins out”). Because my brother and I were strong and healthy and looked very much alike, although my brother was one year older, we were separated out by Jewish camp workers, who whispered to us: “Stay on this side; you at least have a chance to stay alive.” After a cold shower, we were shaved, underwent disinfection, donned the striped inmates' uniform, and had the numbers B-10506 and B-10507, respectively, tattooed on our left forearms. We were separated from our family (parents and five other siblings), and all of our belongings were confiscated. We were assigned to Birkenau barrack 11 together with approximately 1,000 children, mostly twins and dwarfs. I vividly remember on the first evening asking one of the other boys when we would see our parents and siblings again. The boy took me to a crack in the wooden wall of the barrack, pointed to the crematorium chimney with smoke coming out of it, and informed me: “Look, your loved ones are being released through the chimney and dissipated into the wind!” My brother wanted to commit suicide, but I prevented him from doing so, telling him that I would not be able to cope alone; only with combined forces would we have a chance to survive.
After a few days, we were taken to the medical laboratories of Dr. Josef Mengele, who headed medical experimentation in Auschwitz. Since my brother had a beautiful singing voice whereas I had a deep hoarse voice and unashamedly could not sing, Mengele decided to perform medical experiments on our vocal cords. They injected some substance into our anterior necks, which in both of us immediately led to swelling, high fever, vomiting, hoarseness, muteness, and a state of exhaustion for several days. My brother was incapable of swallowing for a prolonged time. These injections were repeated every four to five days for over three months, until Dr. Mengele fled from Auschwitz. On January 18, 1945, we were forced into the notorious death march from Auschwitz and then spent ten days in the freezing cold of winter in sealed livestock wagons, which brought us to Sachsenhausen, a Nazi concentration camp 35 kilometers north of Berlin. Thankfully, we were liberated by the Russian army in April 1945.
In Prague, on our way back home to Budapest, my brother had to be hospitalized for complications resulting from the medical experiments; he lost his voice, and one of his lungs had to be removed. In June 1946, after a prolonged hospitalization, he died. I deeply missed him and was weak, but I found the strength to return to Budapest. However, I found no surviving family members there. I was hospitalized for seven months in Budapest with severe breathing problems.
After this difficult and challenging time, I realized that I had to make a decision: either grieve for the rest of my days or begin rebuilding my life. I chose the latter. I emigrated to Israel in 1948, married, and started to work as a bus driver. Since the medical experiments, I suffered from shortness of breath with worsening hoarseness and swallowing difficulties. In 1965, I lost my voice completely and was able to communicate only in writing for 19 years. In addition, at the sites of the injections, malignant change occurred: I developed what I was told to be “hyperkeratotic papilloma of the larynx with malignant degeneration to squamous cell carcinoma,” which also invaded my esophagus, which led to further breathing and swallowing difficulties. I was forced to undergo major surgical procedures, including radical pharyngectomy, laryngectomy, and neck dissection, followed by reconstruction of my esophagus, larynx, and neck and skin grafting from my right arm. I was very grateful to my competent surgeon, who took a great deal of care in helping me. After more than 20 surgical procedures and tube feeding for many months, I regained reasonable functions; however, I still am unable to speak. But after 19 voiceless years, in 1984 I began to use an innovative German-produced external voice amplifier that enables me to speak with an artificial voice.
My family today consists of two children, five grandchildren, and one great grandchild. Although my formal education was very limited due to political circumstances, I love reading and take great interest in contemporary issues in general and academia in particular.
Looking back, I have no nightmares, and I bear no anger or bitterness toward Dr. Mengele and his medical team. I firmly believe that what helped me overcome adversity and even thrive after Auschwitz was my warm family upbringing despite significant poverty, my sincere love of life, and my desire always to improvise and to find meaning in experience. It was impossible in Auschwitz to know what the next five minutes would bring, and therefore one had to adapt accordingly. This same ability to adapt I believe held me in good stead for my later medical challenges with laryngeal cancer.
Although I generally keep it to myself, I sometimes feel some irritability and frustration toward people who dwell on their traumatic experiences. I feel that survivors of trauma need to take control of their situation, mobilize their inner strength, and move on. I like to quote Primo Levi, also an Auschwitz survivor, whom I met and who turned out to be somewhat of a mentor for me: “The aims of life are the best defense against death.” I also like to dwell on what my surgeon told me, who, after the difficult surgery, informed me that he had accomplished 50% of what was required and now I have to complete the rest. In developing this positive approach, I do not believe that I am in denial or have ignored my experience; I constantly analyze it. Even when sick or broken, one can cry or decide to move on; I choose the latter. I look life in the eye with a smile. I want to help others to do the same.
[Photographs of the selection process at Auschwitz, Mengele, and Mr. Reichenberg are available online as a supplement to this account at ps.psychiatryonline.org.]
Meeting with Ephraim is a delightful experience. He demonstrates no depression, anxiety, or posttraumatic stress disorder and measures very high (86 out of 100) on the Connor-Davidson Resilience Scale. Even the tone of his narrative is revealing—detailed, focused, and impassive but touching. In spite of the inhumane experiments he underwent at Auschwitz-Birkenau, which resulted in severe and lifelong medical side effects, Ephraim seems to have actively managed his experience and retained a positive outlook on life. He appears to epitomize the concept of resilience—a process that demands “flexible adaptation” to the expected inevitable changes in life demands (1). His ability to focus on the positive, prevail over the hardships he experienced, and function to the extent that he did through the trauma says a great deal about the transformative strength of the individual and the capacity to overcome. If anything, Ephraim believes that his traumatic experience strengthened him and his resolve to survive no matter what, resonating very much with the concept of stress-related growth associated with resilience (2). The challenge remains how to capture and describe this effort in order to help others focus on achieving a mentally healthy state rather than on illness associated with the trauma. This consideration resonates with that of the positive psychology movement, which emphasizes the promotion of positive functioning. Echoing the message of psychiatrist Viktor Frankl, who also survived Auschwitz, Ephraim believes that ultimately finding meaning in every stage of his life is what has enabled him to survive with a positive outlook. This is expressed now in his desire to impart a message of hope to the next generation—as he describes it, “to look life in the eye with a smile.”
Ephraim demonstrates many features of dispositional optimism, which assisted him in his return to health or adaptation to the new reality at various traumatic and posttraumatic life moments. Samson and Siam (3) have suggested that healthy or positive outcomes involved in adaptation to major stress demand “a re-established sense of normalcy.” A number of protective processes in his youth may have contributed to his resilience and avoidance of adverse mental health consequences. One factor that stands out in his self-report is his positive early family environment—a factor shown to be highly correlated with resilience (4). He had extremely warm and secure family relationships, as well as extended social support networks (relatives, friends, and devoted teachers as mentors). Ephraim maintained his close relationship with his brother throughout the camps and made it clear to him that only together could they survive (5). Although most children and young people are resilient to trauma, usually this is as a result of obtaining a sense of safety from adults, predictable routines, and consistent support systems (6). Unfortunately none of these support structures were available in Auschwitz. Nevertheless, he prevailed. Personality traits of emotional stability, agreeableness, extraversion, and lower levels of passive coping are associated with greater resilience among persons who experience trauma in their youth (7). Ephraim appears to exhibit many of these characteristics.
There are four potential outcomes for children who have severe traumatic experiences: chronic dysfunction, recovery, resilience, and delayed reactions (8). Ephraim clearly is among the resilient group. Interestingly, Ephraim's brush with severe trauma in his youth may have enabled him to cope in a more positive manner with his later trauma of laryngeal cancer and inability to speak for close to 20 years. Coping with serious stress, such as life-threatening illness, may lead to personal change beyond mere adaptation. Many have termed this “posttraumatic growth,” which leads to functioning and well-being over and above pretrauma levels (9). This results in improved life appreciation, sense of personal strength, and deeper existential and spiritual life, as well as more meaningful interpersonal relationships (10).
Ephraim's inspiring will to survive demonstrates that a positive and resilient attitude toward life may constitute an impressive long-term aid in coping with and overcoming potential traumatic experiences and medical complications. The professional care of Ephraim's dedicated physicians, who have over the years treated the complex side effects of the horrific medical experiments to which he was subjected, demonstrate in contrast the beauty and accomplishment of true medical commitment. Despite the intense exposure to trauma and subsequent mental suffering, most Holocaust survivors have managed to cope and adjust following liberation, with significant success in their occupational, family, and social lives. However, many continue to suffer a great deal, especially in their later years of life when they are facing death once again. What is unique about Ephraim is that he not only coped with and survived the adversity of the Holocaust in general and Auschwitz in particular, he has appeared to thrive. Lessons can be learned from his optimism, positive attitude, sense of humor, and vigor while he continues to thrive into old age.