Transcript Module 3: Interview Considerations

MODULE 3
Prevention through Documentation Project
INTERVIEW CONSIDERATIONS
CONTRIBUTORS:
Türkcan Baykal MD, Human Rights Foundation of Turkey
Allen Keller MD Bellevue/NYU Program for Survivors of Torture
Uwe Jacobs PhD, Survivors International
Kathleen Allden, MD, Indochinese Psychiatric Clinic
Vincent Iacopino, MD, PhD, Physicians for Human Rights
PtD Project (IRCT, HRFT,
REDRESS, PHR)
Module 3 Outline

Preliminary Considerations

Conducting Interviews

Interview Content
PtD Project (IRCT, HRFT, REDRESS, PHR)
Module 3 Outline

Preliminary Considerations

Conducting Interviews

Interview Content
PtD Project (IRCT, HRFT, REDRESS, PHR)
Preliminary Considerations
– Purpose of medical evaluations
– Interview settings
– Trust
– Informed consent and Confidentiality
– Privacy
– Empathy and Objectivity
– Safety and security
PtD Project (IRCT, HRFT, REDRESS, PHR)
Preliminary Considerations
– Procedural Safeguards for Detainees
– Risk of Re-traumatisation
– Gender Considerations
– Interviewing Children
– Cultural and Religious Awareness
– Working with Interpreters
– Transference and Counter-Transference Reactions
PtD Project (IRCT, HRFT, REDRESS, PHR)
Purpose of Examination

Establish facts relating to alleged incidents of
torture

Document physical and psychological evidence of
injuries and abuse

Correlate the degree of consistency between
examination’s findings and the statements of the
individual

Render expert interpretations of findings
PtD Project (IRCT, HRFT, REDRESS, PHR)
Key role of the interview

Effective and appropriate
and interviewing skills
essential to medical
evaluations

Interviews provide
foundation for accuracy in
medical reports in legal
settings
PtD Project (IRCT, HRFT, REDRESS, PHR)
Tasks of the Interview

Information gathering

Emotion handling

Providing Information
PtD Project (IRCT, HRFT, REDRESS, PHR)
Application of Preliminary Interview
Considerations

Recounting events of abuse is extremely
stressful and potentially retraumatising
for the victim.

Listening to accounts of torture/trauma
can be very stressful for the interviewer
(Vicarious traumatisation)

Establishing rapport and eliciting thorough
history takes time
PtD Project (IRCT, HRFT, REDRESS, PHR)
Application of Preliminary Interview
Considerations (continued)

There is variability in degree of physical and
psychological signs, symptoms or consequences
which a torture victim will manifest

There is variability in the manner in which torture
victims conduct themselves in interviews and in
recounting the events of their abuse

There is variability in the amount and detail of
information which an individual will recall with
regards to the events of the trauma
PtD Project (IRCT, HRFT, REDRESS, PHR)
Interview Settings

Safe, comfortable settings

Room with appropriate physical conditions

Access to toilet facilities and refreshment
opportunities- water and tissues within reach

The seating should allow the interviewer and
interviewee to be equally comfortable and at an
appropriate distance, to establish eye contact, and see
each others’ faces

Clinician should choose setting
PtD Project (IRCT, HRFT, REDRESS, PHR)
Trust
Essential component of eliciting an accurate
account of abuse.
 Requires:

– Active listening
– Meticilous communication
– Courtesy
– Genuine empathy
– Honesty
– Safe & comfortable setting
– Establish interviewee’s control over
process (stopping, taking breaks)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Informed Consent

Informed consent requires that the
consenting individual:
– Is mentally competent
– Receives full disclosure of information,
including risks, benefits, and clarification of
the limits of confidentiality
– Understands information provided
– Gives consent voluntarily
– Provides authorisation for consent
PtD Project (IRCT, HRFT, REDRESS, PHR)
Informed Consent
Explain the purpose of the meeting
 Explain the independent but nonadversarial role
 Explain who you are
 Clarify the length and structure of
interview (including time limitations)
 Confidentiality issues
 Right to refuse

PtD Project (IRCT, HRFT, REDRESS, PHR)
Informed Consent
Required elements:
• Introduction of clinician and role (independent,
•
•
•
•
non-adversarial)
Purpose of evaluation
Length and structure of interview (including
time limitations)
Confidentiality issues (such as limitations)
Explanation of right to refuse
PtD Project (IRCT, HRFT, REDRESS, PHR)
Confidentiality

Clinicians have a duty to maintain
confidentiality of information and to
disclose information only with the patient’s
informed consent

The patient should be clearly informed of
any limits to the confidentiality of the
evaluation and of any legal obligations for
disclosure of the information.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Privacy

Degree of confidentiality and security
determines whether questions can be asked
safely

Police or other law enforcement should
never be present in examination room

Police presence should be noted in the
medical report and may be grounds for
disregarding a “negative” report
PtD Project (IRCT, HRFT, REDRESS, PHR)
Empathy and Objectivity

Medico-legal evaluations should be conducted
with objectivity and impartiality

Objectivity not in contradiction with being
empathic
– maintain professional boundaries.
– same time acknowledge pain and distress when
observed
PtD Project (IRCT, HRFT, REDRESS, PHR)
Safety and Security

Consider the possibility of reprisals

Do not promise a level of security that cannon be
achieved

Do not conduct an evaluation if reprisal is certain

Safeguard identifying information

Evidence of torture/ill treatment should result in
a transfer of custody to judicial authorities
PtD Project (IRCT, HRFT, REDRESS, PHR)
Procedural Safeguards

Forensic medical evaluation of detainees requires official
written request and services should be independent from
police/prison system and free of charge

Detainees, their lawyers or relatives:
– right to request medical evaluation to seek evidence of torture
or CID
– Right to obtain second/alternative medical evaluation by
qualified physician even if previously examined

Mandatory that detainees undergo a preliminary medical
examination at the time of detention; repeat evaluation upon
release
PtD Project (IRCT, HRFT, REDRESS, PHR)
Procedural Safeguards

The detainee should:
– be taken to exam by officials not working in his/her detention
site
– be examined by qualified doctor
– be examined without police officer present

If police, soldier, warden, or other law enforcement officers
present:
– Should be noted by physician in report
– May be grounds for disregarding “negative” medical report

If medico-legal evaluation, should use a standardized medical
report form which includes:
– allegations of abuse
– details of injuries
– psychological findings
– explanations of patient
– opinion of doctor
PtD Project (IRCT, HRFT, REDRESS, PHR)
Procedural Safeguards

Medical report:
– should never be transferred/copied for law enforcement
– should be transmitted to official requesting report

If exam supports allegations of torture or illtreatment, detainee:
– should not be returned to detention site
– should be presented to competent prosecutor or judge

Access to the lawyer should be provided at the
time of the medical examination.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Risk of re-traumatisation
PtD Project (IRCT, HRFT, REDRESS, PHR)

Structure interview to minimize
risk of re-traumatizing torture
survivor

Balance two important
requirements:
– need to obtain detailed,
accurate account
– importance of respecting needs
of person being interviewed
Risk of re-traumatisation
Avoid any manner, approach, style which
may remind survivor of torture
situation;
– Avoid authoritative instructions and
–
–
–
–
questions
Do not make the patient wait
Give the patient control
Give time, space for his/her own
questions/needs
Provide comfortable setting, adequate time
PtD Project (IRCT, HRFT, REDRESS, PHR)
Gender Considerations

Same-sex interviewing preferable: respect
individual choices, if possible

Sexual abuse common among torture survivors
– Influences examination
– Male survivors may be more reluctant to
disclose sexual abuse

Consider cultural and individual factors in
determining appropriate interviewing strategy
PtD Project (IRCT, HRFT, REDRESS, PHR)
Interviewing Children

Involve parent or guardian
– Required for consent
– Required presence for detailed history/exam in

Where possible, the family should be treated
together

Child’s injuries should be documented and managed
by paediatric specialists

Ensure safety and comfort

Short attention spans may require frequent breaks
PtD Project (IRCT, HRFT, REDRESS, PHR)
Cultural and Religious
Awareness

Clinicians should be aware of beliefs and
cultural norms

Interpreters may facilitate understanding

Interviewers should make sure to conduct
him or herself in a manner that does not
offend cultural or religious sensibilities
PtD Project (IRCT, HRFT, REDRESS, PHR)
Working with Interpreters

Interpreters have similar professional
obligations to the examiner

Interpreter should not be
– Law enforcement
– Government employee
– Friends or relatives (as they may not be
impartial, can be important witnesses)

Examiner should maintain contact and talk
to examinee, not interpreter
PtD Project (IRCT, HRFT, REDRESS, PHR)
Transference & Counter-transference

Clinicians should be aware of
potential emotional reactions that
evaluations of severe trauma may
elicit in interviewee and interviewer

These emotional reactions are known
as transference and countertransference.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Transference

Transference refers to the feelings a
survivor has towards the clinician that
relate to past experiences but which are
misunderstood as directed towards the
clinician personally
PtD Project (IRCT, HRFT, REDRESS, PHR)
Transference

Evaluator’s questions may be experienced as:
– forced exposure akin to an interrogation
– sign of mistrust or doubt on the part of the
examiner
– interview situation may be perceived as
ressembling torture situation

The evaluator may be perceived as
– having voyeuristic and sadistic motivations
– a person with authority (in a positive or
negative sense)
– being on the side of the enemy
PtD Project (IRCT, HRFT, REDRESS, PHR)
Transference

For all these and other similar perceptions,
the subject may experience:
– distress
– fear
– mistrust
– forced submission
– anger, rage
– shame
– worry or suspicion
– or may be too trusting and expectant
PtD Project (IRCT, HRFT, REDRESS, PHR)
Counter-transference

The clician’s should also be aware of
his/her own potential personal reactions,
feelings and how that might influence the
interviewer’s perceptions and judgments
PtD Project (IRCT, HRFT, REDRESS, PHR)
Counter-transference

Common counter-transference reactions
include:
– Avoidance, withdrawal, defensive indifference
– Disillusionment, helplessness, hopelessness and
over-identification
– Omnipotence and grandiosity in the form of
feeling like a savior, the great expert on trauma
or the last hope of the survivor
– Feelings of insecurity, feelings of guilt,
excessive rage toward torturers and
persecutors or toward the individual
PtD Project (IRCT, HRFT, REDRESS, PHR)
Transference/Counter-transference

Important sources of information about the
psychological state of torture survivor

Clinician’s effectiveness can be compromised when
counter-transference is acted upon rather than
reflected upon

Clinicians engaged in the evaluation and treatment of
torture victims should evaluate countertransference and obtain supervision and consultation
from a colleague

Individual and group support may help to prevent
and/or mitigate secondary traumatisation
PtD Project (IRCT, HRFT, REDRESS, PHR)
Possible Effects of Countertransference Reactions




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
Underestimating severity of consequences
of torture
Forgetting details
Leading to disbelief regarding veracity of
alleged torture
Failure to establish necessary empathic
approach
Over-identification with survivor
Vicarious traumatisation, burn-out
Difficulty in maintaining objectivity
PtD Project (IRCT, HRFT, REDRESS, PHR)
Module 3 Outline

Preliminary Considerations

Conducting Interviews

Interview Content
PtD Project (IRCT, HRFT, REDRESS, PHR)
Conducting Interviews
Types of Questions
 Cognitive Techniques
 Summarising and Clarifying
 Difficulty Recalling and Recounting
 Assessing Inconsistencies

PtD Project (IRCT, HRFT, REDRESS, PHR)
Types of Questions

Utilize open ended
questions
– “Can you tell me what
happened?”
– “Tell me more about that.”

Based on information
elicited, more specific
details should be sought
PtD Project (IRCT, HRFT, REDRESS, PHR)
Techniques of Questioning

Listening is more important than
asking questions

Leading questions may be good or bad

Consider using checklists
PtD Project (IRCT, HRFT, REDRESS, PHR)
Cognitive Techniques

Free narrative in interviewee’s own
words
– Followed by direct question for
clarification
– Clarification of chronological order of
events

Descriptions from another point of
view (eg. an observer)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Summarizing and Clarifying

Improve accuracy of information by:
– Clarifying details
– Summarise key points periodically
– Consider follow-up interview to address
outstanding questions or any
inconsistencies
PtD Project (IRCT, HRFT, REDRESS, PHR)
Difficulties in Recalling and Recounting
Factors directly related to the
torture experience
Factors related to the
psychological impact of
torture
Cultural factors
Factors related with the interview
conditons or communication barriers
PtD Project (IRCT, HRFT, REDRESS, PHR)
Difficulties in Recalling and Recounting

Factors directly related to the
torture experience
– Torture itself such as
blindfolding, drugging, lapses of
consciousness, etc.
– Disorientation in time and place during
torture
– Neuro-psychiatric memory impairment from head injuries,
suffocation, near drowning, starvation, hunger strikes or
vitamin deficiencies
– Experiencing repeated and similar events may have led to
difficulties recalling details of specific events
PtD Project (IRCT, HRFT, REDRESS, PHR)
Difficulties in Recalling and Recounting

Factors related to the psychological impact
of torture
– Memory disturbances related to PTSD
or Depression
– Coping mechanisms such as denial and
avoidance
– Other psychological symptoms such as
concentration difficulties,
fragmentation or repression of
traumatic memories, confusion,
dissociation, amnesia
– Feelings of guilt or shame
PtD Project (IRCT, HRFT, REDRESS, PHR)
Difficulties in Recalling and Recounting

Factors related to cultural norms
– Cultural differences in the perception of time
– Culturally prescribed sanctions that allow
traumatic experiences to be revealed only in
highly confidential settings.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Difficulties in Recalling and Recounting

Factors related to the interview conditons
or communication barriers
–
–
–
–
–
–
–
–
Fear of placing oneself or others at risk
Lack of trust
Lack of feeling safe
Environmental barriers such as lack of privacy,
inadequate time
Physical barriers such as pain or other discomforts
Socio-cultural barriers such as the gender of the
interviewer, language and cultural differences
Transference/counter-transference reactions
Misconducted and/or badly structured interviews
PtD Project (IRCT, HRFT, REDRESS, PHR)
Assessing Inconsistencies
Problems recalling and recounting
information commonly manifest as
inconsistencies in an individual’s
testimony.
Be aware that inconsistencies do not
mean that allegations of torture are
false.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Assessing Inconsistencies

If possible, the investigator should ask for
further clarification

When this is not possible;
The investigator should look for other evidence. A
network of consistent supporting details can
collaborate and clarify the person’s story.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Assessing Inconsistencies
If the clinician suspects fabrication;

The clinician should try to identify potential
reasons for exaggeration or fabrication

Also, should keep in mind that such fabrication
requires detailed knowledge about traumarelated symptoms and findings that individuals
rarely possess
PtD Project (IRCT, HRFT, REDRESS, PHR)
Assessing Inconsistencies
If the clinician suspects fabrication;

Additional interviews should be scheduled to help
clarify inconsistencies in the report.

Family or friends may be able to corroborate
details of the history.

He/she should refer the individual to another
clinician and ask for the colleague’s opinion.

The suspicion of fabrication should be
documented with the opinion of two clinicians
PtD Project (IRCT, HRFT, REDRESS, PHR)
Module 3 Outline

Preliminary Considerations

Conducting Interviews

Interview Content
PtD Project (IRCT, HRFT, REDRESS, PHR)
Interview Content
– Identification and Introduction
– Psychosocial History- Pre-Arrest
– Past Medical History
– Summary of Detention(s) and Abuse
– Circumstances of Detention(s)
– Prison/Detention Place Conditions
– Allegations of Torture and Ill Treatment
– Review of Symptoms
– Psychosocial History (post-arrest)
– Assessments of Physical and Psychological Evidence
– Physical Examination
– Closing
– Indications for Referral
PtD Project (IRCT, HRFT, REDRESS, PHR)
Identification & Introduction
Clinician introduction followed by:
 Explanation of purpose of evaluation
Review conditions of evaluation and overall content of
interview
– detailed questions of events before, during, after
alleged torture
– physical examination
– possibility of photographs


Likely benefits and risks of evaluation

Any questions or concerns of interviewee

Obtaining consent to proceed
PtD Project (IRCT, HRFT, REDRESS, PHR)
Components of the History
Psychosocial History-Pre-Arrest
 Past Medical/Psychological History
 Trauma History
 Review of Symptoms

PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychosocial History Pre-Arrest
Occupation/School
 Relations with friends and family
 Past use of alcohol and drugs
 Information about accusations and
why individual thinks he/she was
detained and tortured

PtD Project (IRCT, HRFT, REDRESS, PHR)
Past Medical History

Medical history
– Prior medical, surgical
– Medications
– History of injuries/wounds before detention or
unrelated to alleged mistreatment

Psychiatric History
– Prior mental or psychological disturbances
– Prior treatment received including medications
or hospitalisations
PtD Project (IRCT, HRFT, REDRESS, PHR)
Summary of Detention and
Abuse

Elicit summary information, including:
– Dates
– Places
– Duration of detention
– Overall frequency and duration of
alleged torture sessions
PtD Project (IRCT, HRFT, REDRESS, PHR)
Circumstances of Detention


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When and where did this occur?
What was individual doing at time of
abuse?
Who was there?
What were these individuals wearing (eg.
military, police, civilian clothes)
What was said? (eg. threats)
Were official charges provided?
Any witnesses?
PtD Project (IRCT, HRFT, REDRESS, PHR)
Prison/Detention Conditions
Name of place
 Transportation to place
 Conditions of cell/room (eg. size,
ventilation, temperature, hygiene,
overcrowding, solitary confinement)
 Access to food/water, toilet facilities.
 Contact with family, lawyers, health
professionals

PtD Project (IRCT, HRFT, REDRESS, PHR)
Allegations of Torture and
Ill Treatment
What forms of torture/abuse did
individual suffer?
 For each form of abuse note

– body position/restraint
– nature of contact, including duration and
frequency, area of the body affected.

Was there any bleeding, head trauma
or loss of consciousness?
PtD Project (IRCT, HRFT, REDRESS, PHR)
Methods of Torture (Physical)

Blunt trauma: punch, kick, slap, whips, wires, truncheons, falling

Crushing body parts: heavy roller to thighs/back, fingers

Suspension/Stretching limbs apart

Burns: electric shock, cigarettes, heated instrument, chemical

Asphyxiation: wet or dry

Penetrating injuries: stab and gunshot wounds, wires under nails

Chemical exposures: salt, chili, gasoline

Sexual: humiliations, molestation, instrumentation, rape

Exposure to extremes of temperature:

Prolonged constraint of movement

Traumatic removal of appendages and organs: digits, limbs, kidneys
PtD Project (IRCT, HRFT, REDRESS, PHR)
Methods of Torture
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Deprivations
Humiliations: verbal abuse, performance of humiliating acts
Threats: death, harm to family, further torture, mock
executions
Psychological techniques :
– forced “betrayals,”
– learned helplessness
– harm self and/or others
Violation of taboos
Behavioral coercion
Forced to witness torture being inflicted on others
Post-Release
PtD Project (IRCT, HRFT, REDRESS, PHR)
Allegations of Torture and
Ill Treatment
Description of torture instruments
 Clothing/Disrobing
 What was said during the abuse?
 Sexual Assault?
 What was the condition of the person
at the end of the torture?

PtD Project (IRCT, HRFT, REDRESS, PHR)
Review of Symptoms

Acute Symptoms (at time or
immediately following torture/ill
treatment)



Physical Symptoms (Module 5)
Psychological Symptoms (Module 6)
Chronic Symptoms


Physical Symptoms (Module 5)
Psychological Symptoms (Module 6)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychosocial History Post-Arrest
Continued harassment/persecution
 Fear for safety following release
from detention (alleged victim &
family/friends)
 Inability to return to work or school
 Refugee experiences, including
fleeing country of origin and
difficulties in host country

PtD Project (IRCT, HRFT, REDRESS, PHR)
Assessments of Physical and
Psychological Evidence of
Torture
The content of interviews varies
among clinicians who conduct separate
medical evaluations of physical and
psychological evidence of torture.
 See Modules 5 and 6 for additional
interview considerations.

PtD Project (IRCT, HRFT, REDRESS, PHR)
Physical Examination

The physical examination, and any
related photographs of physical
findings, usually conducted after all
other interview components, including
the psychological evaluation

See Module 5
PtD Project (IRCT, HRFT, REDRESS, PHR)
Additional Sources of
Information
 Additional
 Medical
 Legal
interviews
and other records
documents
PtD Project (IRCT, HRFT, REDRESS, PHR)
Concluding the Interview

Information gathering


Emotion Handling


ask if there is anything else the individual
wishes to tell you.
recognition, acknowledgment, empathy
Providing Information


explanation of subsequent process
appropriate referrals/resources for follow
up care
PtD Project (IRCT, HRFT, REDRESS, PHR)
Considerations for Referral

Assess possible therapeutic needs
– Clinical
– Social
Be aware of local support services
 Obtain necessary consultations or
examinations

PtD Project (IRCT, HRFT, REDRESS, PHR)