Oftentimes when Mary Tornabene, RN, FNP, sees a patient for the first time, the entire visit and exam take place on the floor.
It’s not that her facility lacks a proper exam table or chairs, instead Tornabene’s unique patients are more comfortable on the ground — a cultural trait most Americans might consider peculiar.
But many of the foreign patients visiting Chicago’s Rogers Park-based Marjorie Kovler Center for the Treatment of Survivors of Torture identify the floor as comfortable and safe, unlike an exam table, which might resemble the platform on which they were tortured.
“I might be the first healthcare provider to see them after their torture, and what we consider to be our norm is not theirs,” Tornabene says. “These clients are anxious and scared and they may have significant psychological issues, such as post-traumatic stress, anxiety, and depression. And because I might be the first person in the healthcare system they’ve seen, I want to get them off to a good start.”
Last year alone, 365 torture survivors, most of them African nationals seeking asylum in the United States, were treated at the Kovler Center. Operated through the Heartland Alliance for Human Needs and Human Rights, the center has provided mental and physical health and various support services to more than 1,400 torture survivors from 74 different countries since opening 20 years ago.
Although it’s not clear how many torture survivors live in Cook County, The Center for Victims of Torture estimates as many as 500,000 survivors live in the United States.
Frequently, referrals to Kovler are made by Alliance’s partners — social service agencies such as the National Immigrant Justice Center, and medical facilities such as Cook County Hospital system. But many Kovler clients find their way to the center through word of mouth, says Mary Lynn Everson, MS, managing director of the Kovler Center. In addition to primary care services, Tornabene provides survivors dozens of specialty services — psychiatric, massage, orthopedic, dental, etc. — that are delivered pro bono to clients by a network of more than 100 professionals.
Each patient’s unique complexity is individually addressed by Tornabene, a nurse with the alliance for 17 years.Mary Tornabene, RN, FNP, of the Marjorie Kovler Center for the Treatment of Survivors of Torture in Chicago, checks the blood pressure of a case manager at the center. Procedures often are demonstrated to patients before a test is performed to avoid additional trauma.
At the center, at an alliance facility, or in the patients’ homes, she tries to learn about their trauma by asking, typically through interpreters, what experience they had in their home country that compelled them to leave and come to the United States.
Knowing the way survivors were injured helps Tornabene understand their fears or reservations about treatment. For example, strapping and inflating a blood pressure cuff on the arm of a survivor whose arms were confined during torture can be completely devastating. And referring a rape survivor for a Pap smear too hastily could re-victimize the patient.
While treating her patients according to their individual needs is the first step toward developing a trusting rapport, providing clients with a sense of control over the appointment further advances that trust.
“The first time we walk into the room, I say, ‘This is me. This is the room. Where do you want to sit? Where would you like my chair?’
“I will physically arrange the room the way they want it,” she explains. “The biggest thing I try to do is empower them by telling them that this is their healthcare experience. I ask what would they like to happen and tell them they can say no and stop at any time.”
Even after the patient has gained confidence that he or she is controlling the appointment, Tornabene models each test and procedure to ensure the actions won’t re-traumatize the survivor.
“If that table or the light or any item re-creates the setting of torture, you need to find an alternative,” Everson says. “If you’re committed to providing the service, you have to find a way that works for the individual, which makes the practitioner have to think outside the box to perform the service in a different way than the way they were trained.”
If a patient needs an ECG, which, because of the attachment of electrodes, is a testing mechanism that resembles electric shock injury, he or she first will watch a staff member undergo the test. Then, the patient might touch the machine and electrodes and finally, during another visit, receive the test.
Some patients need months to build up the confidence to undergo an MRI, says Tornabene, explaining the confinement and noise — akin to a rapid-fire machine gun — mimics several torture scenarios.
Because most providers aren’t given the luxury of innovation in mainstream facilities, treating torture survivors in the traditional setting can be extremely difficult, adds Everson.
“It’s frustrating to some providers because clients need certain services and they want to refer them,” Everson explains. “But because you need to let the individual guide what needs to be done and let the survivor set the pace for when services can be accepted, the client is often not ready, so the referral can’t be made.”
Another challenge in treating torture survivors is understanding cultural references to pain. Sometimes patients complain of headaches; however, the aches are memories of the devastating situations being replayed in their heads. Or sometimes patients have chest pains stemming from depression, grief, and despair related to emotional traumas.
High blood pressure, heart palpitations, stress-induced asthma, and stress-induced diabetes are only a few diseases listed as long-term effects of torture, according to medical experts.
Tornabene commonly treats patients with orthopedic complaints, back pain, headaches, and abdominal pain. However, providers also must remain always cognizant of the psychological manifestations of torture.
“We look for the psychological effects that are a result of physical torture,” she says. “All our clients see mental health professionals at some point. Whether they see me or them first really depends on their needs.”
While years of training have taught Tornabene to quickly identify these needs, the most important component of her approach is patience and kindness.
“You need to go in wanting to treat them kindly and knowing that’s going to take different skills than treating someone else kindly,” she says.