PtD Project (IRCT, HRFT, REDRESS, PHR)
MODULE 3MODULE 3Prevention through Documentation ProjectPrevention through Documentation Project
INTERVIEW CONSIDERATIONS
CONTRIBUTORS:
Türkcan Baykal MD, Human Rights Foundation of TurkeyAllen Keller MD Bellevue/NYU Program for Survivors of Torture
Uwe Jacobs PhD, Survivors InternationalKathleen Allden, MD, Indochinese Psychiatric Clinic
Vincent Iacopino, MD, PhD, Physicians for Human Rights
Module 3 OutlineModule 3 Outline
Preliminary Considerations
Conducting Interviews
Interview Content
PtD Project (IRCT, HRFT, REDRESS, PHR)
Module 3 OutlineModule 3 Outline
Preliminary Considerations
Conducting Interviews
Interview Content
PtD Project (IRCT, HRFT, REDRESS, PHR)
Preliminary ConsiderationsPreliminary 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 ConsiderationsPreliminary 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 ExaminationPurpose 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)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Key role of the interviewKey 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
Tasks of the InterviewTasks of the Interview
Information gathering
Emotion handling
Providing Information
PtD Project (IRCT, HRFT, REDRESS, PHR)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Application of Application of Preliminary Preliminary Interview Interview ConsiderationsConsiderations
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
Application of Application of Preliminary Preliminary Interview Interview ConsiderationsConsiderations (continued) (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 SettingsInterview 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)
PtD Project (IRCT, HRFT, REDRESS, PHR)
TrustTrust 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
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
Informed ConsentInformed Consent
Explain the purpose of the meetingExplain the independent but non-
adversarial roleExplain who you areClarify the length and structure of
interview (including time limitations)Confidentiality issuesRight to refuse
PtD Project (IRCT, HRFT, REDRESS, PHR)
Informed ConsentInformed 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)
PtD Project (IRCT, HRFT, REDRESS, PHR)
ConfidentialityConfidentiality
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)
PrivacyPrivacy 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 ObjectivityEmpathy 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 Safety and and SSecurityecurity 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 ill-treatment, 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)
RRisk of re-traumatisationisk of re-traumatisation
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
PtD Project (IRCT, HRFT, REDRESS, PHR)
Risk of Risk of re-traumatisatre-traumatisatiionon
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
Gender ConsiderationsGender 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 ChildrenInterviewing 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 Cultural and Religious AwarenessAwareness
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 InterpretersWorking 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)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Transference & Counter-Transference & Counter-transferencetransference
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 counter-transference.
PtD Project (IRCT, HRFT, REDRESS, PHR)
TransferenceTransference
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)
TransferenceTransference 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)
TransferenceTransference
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-transferenceCounter-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-transferenceCounter-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-transferenceTransference/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 counter-transference and obtain supervision and consultation from a colleague
Individual and group support may help to prevent and/or mitigate secondary traumatisation
Possible Effects of Counter-Possible Effects of Counter-transference Reactionstransference Reactions
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 OutlineModule 3 Outline
Preliminary Considerations
Conducting Interviews
Interview Content
PtD Project (IRCT, HRFT, REDRESS, PHR)
Conducting InterviewsConducting Interviews
Types of QuestionsCognitive TechniquesSummarising and ClarifyingDifficulty Recalling and RecountingAssessing Inconsistencies
PtD Project (IRCT, HRFT, REDRESS, PHR)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Types of QuestionsTypes of QuestionsUtilize open ended
questions– “Can you tell me what
happened?”– “Tell me more about
that.”
Based on information elicited, more specific details should be sought
Techniques of QuestioningTechniques 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 TechniquesCognitive Techniques
Free narrative in interviewee’s own words– Followed by direct question for
clarification– Clarification of chronological order of
eventsDescriptions from another point of
view (eg. an observer)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Summarizing and Summarizing and ClarifyingClarifying
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)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Difficulties in Difficulties in RRecalling and ecalling and RRecountingecounting
Factors directly related to the torture experience
Factors related to the psychological impact of torture
Factors related with the interview conditons or communication barriers
Cultural factors
PtD Project (IRCT, HRFT, REDRESS, PHR)
Difficulties in Difficulties in RRecalling and ecalling and RRecountingecounting
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 Difficulties in RRecalling and ecalling and RRecountingecounting
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 Difficulties in RRecalling and ecalling and RRecountingecounting
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 Difficulties in RRecalling and ecalling and RRecountingecounting
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)
!!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.
Assessing InconsistenciesAssessing Inconsistencies
PtD Project (IRCT, HRFT, REDRESS, PHR)
Assessing InconsistenciesAssessing 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 InconsistenciesAssessing 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 fabricationrequires detailed knowledge about trauma-related symptoms and findings that individuals rarely possess
PtD Project (IRCT, HRFT, REDRESS, PHR)
Assessing InconsistenciesAssessing InconsistenciesIf 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
Module 3 OutlineModule 3 Outline
Preliminary Considerations
Conducting Interviews
Interview Content
PtD Project (IRCT, HRFT, REDRESS, PHR)
Interview ContentInterview 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)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Identification & IntroductionIdentification & IntroductionClinician 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
Components of the HistoryComponents of the History
Psychosocial History-Pre-ArrestPast Medical/Psychological HistoryTrauma HistoryReview of Symptoms
PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychosocial History Pre-Psychosocial History Pre-ArrestArrest
Occupation/SchoolRelations with friends and familyPast 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 HistoryPast 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 Summary of Detention and Abuseand 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 Circumstances of DetentionDetention
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 Prison/Detention ConditionsConditions
Name of placeTransportation to placeConditions 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 Allegations of Torture and Ill TreatmentIll 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 (Methods of Torture (PhysicalPhysical))
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 TortureMethods of Torture
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 Allegations of Torture and Ill TreatmentIll Treatment
Description of torture instrumentsClothing/DisrobingWhat 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 SymptomsReview 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-Psychosocial History Post-ArrestArrest
Continued harassment/persecutionFear for safety following release
from detention (alleged victim & family/friends)
Inability to return to work or schoolRefugee experiences, including
fleeing country of origin and difficulties in host country
PtD Project (IRCT, HRFT, REDRESS, PHR)
Assessments of Physical and Assessments of Physical and Psychological Evidence of Psychological Evidence of
TortureTorture
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 ExaminationPhysical 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 Additional Sources of InformationInformation
Additional interviews
Medical and other records
Legal documents
PtD Project (IRCT, HRFT, REDRESS, PHR)
Concluding the InterviewConcluding the Interview
Information gathering ask if there is anything else the individual
wishes to tell you.
Emotion Handling recognition, acknowledgment, empathy
Providing Information explanation of subsequent process appropriate referrals/resources for follow
up care
PtD Project (IRCT, HRFT, REDRESS, PHR)
Considerations for ReferralConsiderations for Referral
Assess possible therapeutic needs– Clinical– Social
Be aware of local support servicesObtain necessary consultations or
examinations
PtD Project (IRCT, HRFT, REDRESS, PHR)
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