March 2007 | Back to Table of Contents

Pulse

Hidden Hurt

Primary care providers play an essential role in identifying victims of trauma and torture.

The young Liberian woman had been dead for two months before she was found in her Minneapolis apartment. There was no next of kin to call and no money to bury her. Her father was in Ivory Coast and her mother was still in Liberia. So a committee was formed to raise the funds for her funeral.

No one knows exactly what happened to the woman—her body was too badly decomposed for an autopsy to be done. Friends said she had dropped out of school, lost her job, and became withdrawn during the weeks prior to her death. But Doris Parker, who chaired the fundraising effort and emigrated from Liberia herself about 20 years ago, can imagine what happened: “She went through the war. She was a refugee in Ivory Coast. … She was isolated, she must have been depressed.”

Parker, a registered nurse and head of Liberian Women’s Initiative, a social service agency in the Twin Cities, calls the situation “classic” and says that some level of depression is nearly universal among the Liberians who have landed in Minnesota—an estimated 20,000 of whom are living in Brooklyn Park and Brooklyn Center. All, she says, have been separated from loved ones. Many don’t know whether family and friends are alive or dead. Others have been beaten or injured themselves, and the majority who came to the United States after 1990, when Liberia disintegrated into civil war, have witnessed killings and beatings or know people who experienced those things.

More than a million Liberians, about a third of the population, were forced from their homes during 14 years of civil war, which began around 1990. A 2003 survey of Liberian refugees who fled to neighboring Sierra Leone found that 91 percent had been beaten, shot at, abducted, raped, forced into labor, or had witnessed a killing.

But Parker says that Liberians are hesitant to talk about such experiences and the emotional scars they leave. What refugees from war-torn countries are more likely to do, she and other experts say, is show up in their doctor’s office with an ache or a pain. “They take the psychological and emotional issues and put them somewhere in their bodies,” says Erin Mehta, R.N., Ph.N., a clinic manager and trainer for the Center for Victims of Torture (CVT), a Minneapolis-based nonprofit outpatient mental health clinic.

Unaware of their patients’ past, doctors struggle to diagnose the cause of pain. And patients, unaware that past trauma may be related to their physical problems, fail to talk. Health care providers become frustrated, Mehta says, because patients keep returning with the same complaints. And patients are frustrated because they’re not getting well.

Ideally, she says, providers who understand the connection between war trauma and somatic complaints should work alongside mental health professionals to treat such patients.

Caught Unaware
That wasn’t happening in any of the clinics in Brooklyn Park and Brooklyn Center when CVT staff became aware of the increasing number of Liberians living there. A 2004 community needs assessment revealed that there were no real mental health services at all in the area.

The two communities, just north of Minneapolis, were experiencing a new phenomenon, an influx of refugees and immigrants to the suburbs. They didn’t come in waves, as did, for example, the Hmong or the Somalis to the center cities. Instead, a steady stream of Liberians and other West Africans trickled in over a decade.

The CVT estimates that 8,500 of those newcomers experienced torture. With so many needs and so few mental health resources available, the organization decided to help train primary care providers in how to work with such patients.

In January of 2006, CVT staff interviewed 32 immigrant patients at the Brookdale Park Nicollet Clinic to determine just what kind of information they were sharing with their doctors. Nearly three-fourths said they had never discussed with their doctor the political conflict in their home country. A third reported that no doctor had ever asked them about the conflict and the ways they’d been affected by it. Most said they would like to talk with their doctor; yet, many said they did not consider the impact of war on them to be a medical issue.

Conversation Starters
David R. Johnson, M.D., M.P.H., a psychiatrist at the Minneapolis Veterans Affairs Medical Center and a medical director for the CVT, believes that it is the primary care provider’s role to initiate discussions about a patient’s history of trauma or
torture.

Physical Signs and Symptoms of Torture Scars Musculoskeletal pain Foot pain Hearing loss Limb amputation Dental pain Vision problems Headaches Feeling dizzy, faint, or weak Chest pain Fast heart beat Stomach pain or nausea Shaking or trembling Cold hands or feet Hot or burning feeling Night sweats Source: Center for Victims of Torture

But, he says, doctors typically don’t know how to broach the topic and also fear the response they might receive. “The fear in the provider is that everything will flow out, and they won’t be equipped to handle it,” he says.

Johnson says he starts the conversation something like this: “There are some common experiences that others have told me about. Have any of these ever happened to you?” Then he lists such things as physical assault and works his way up to rape or torture. “The most important thing isn’t how you word it, but it’s your tone or attitude … making it seem like it can happen to anyone, and they can feel comfortable telling you.”

Deborah Boehm, a certified nurse practitioner at Hennepin County Medical Center’s adult medicine clinic, revamped her whole patient approach after working with immigrants for the last decade.

Boehm, who regularly works with refugees from Somalia, Liberia, and other countries, has developed a four-step model for people presenting with chronic unexplained physical complaints. (She notes that the steps don’t necessarily correspond with an office visit.)

The first is stabilization or management of the acute problem. This involves taking the patient’s history and initiating tests to rule out organic causes. She notes that she rarely touches a patient until at least the second visit.

The second step, perhaps during the second or third visit, involves reassuring the patient that he or she is well physically. While reviewing lab and other test results, Boehm says such things as, “Your liver is working well. Your kidneys are working well. There doesn’t appear to be a problem with your heart.”

By the third or fourth visit, Boehm believes she has established enough of a bond with a patient that she may begin to introduce the idea of a psychological problem. She spends time on pleasantries, which, she says, is very important in most other cultures. Then she might say, “So far, we haven’t been able to find a disease that’s causing your symptoms. We’ve tried a number of medicines, and you’re still not feeling better.” She might then present a couple of more treatment options such as prescribing an SSRI, which she describes as a medicine that may help to “calm” the body, and referring the patient to a physical therapist.

The fourth step is referral to a psychotherapist. “When people have pain like this, I have found that it comes from carrying memories of hard times,” she might tell the patient. She’ll mention that in addition to taking medicine, talking about what happened might decrease their pain. And then she walks down the hallway to the office of psychologist Mary Bradmiller, Ph.D., and brings her back to meet the patient, explaining that she and Bradmiller will work together to help the patient.

Boehm has shared her approach with providers at Park Nicollet clinics in Minneapolis and in Brooklyn Center. But she knows she has a couple of advantages over most primary care providers. For one thing, she has 30-minute appointment slots, compared with the 15 minutes allotted for patient visits in many clinics. Second, she refers patients to a psychologist right down the hall.

Bradmiller says the fact she comes recommended by a trusted provider lends her credibility with patients, who would normally view mental health treatment with disdain. And she says her immigrant patients seem to like the fact that two experts are working on their problem.

Doris Parker says that because mental health and mental illness are taboo subjects in the Liberian community, physicians need to teach people how their exposure to trauma might affect them physically. If people don’t understand, they’ll focus only on getting treatment for the physical manifestations, she says. “I think it’s up to the professional to determine what those symptoms mean, to put things together.”—Carmen Peota