MODULE 3 Prevention through Documentation Project

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)

Interview Content PtD Project (IRCT, HRFT, REDRESS, PHR) 3

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) 5

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) The importance of obtaining the person’s trust in such situations cannot be stressed enough. However, it is even more important not to, even unwittingly, betray that trust Trust is an essential component of elicining an accurate acoound of abuse. Earning the trust of someone who has experienced torture or other forms of abuse requires active listenining, meticulous communication, courtesy and genuine empathy and honesty. 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 non-adversarial 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) 15

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 Ensuring procedural safeguards for detainees is essential for the safety and security of detainees, to earn the detainees trust, respect his or her privacy, and ensure confidentiality. Disregard for certain procedural safeguards may not only result in inaccurate medical evaluation, but also the possibility of administrative and/or criminal santions against the medical expert responsible for forensic documentation of torture and ill treatment. PtD Project (IRCT, HRFT, REDRESS, PHR) 20

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) 21

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) 22

Risk 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 Probing interviewing may remind the examinee of interrogation during torture Emotional expression or outbursts should be expected and tolerated The examiner may not be trusted or may be resisted on the basis of feeling exposed Fears may include that information will be leaked to persecutors A subjective assessment has to be made by the evaluator about whether and to what extent pressing for details is necessary for the effectiveness of the report in court, especially if the claimant demonstrates obvious signs of distress. PtD Project (IRCT, HRFT, REDRESS, PHR)

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 counter-transference. 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 When listening to individuals speak of their torture clinicians should expect to have personal reactions and emotional responses themselves. Understanding these personal reactions is crucial because they can have an impact on one’s ability to evaluate and address the physical and psychological consequences of torture. Reactions may include: - Avoidance, withdrawal and defensive indifference in reaction to being exposed to disturbing material. This may lead to forgetting some details and underestimating the severity of physical or psychological consequences; - Disillusionment, helplessness, hopelessness and overidentification that may lead to symptoms of depression or vicarious traumatization, such as nightmares, anxiety and fear; - Omnipotence and grandiosity in the form of feeling like a saviour, the great expert on trauma or the last hope for the survivor’s recovery and well-being; - Feelings of insecurity about professional skills when faced with the gravity of the reported history or suffering. This may manifest as lack of confidence in the ability to do justice to the survivor and unrealistic preoccupation with idealized medical norms; - Feelings of guilt over not sharing the torture survivor’s experience and pain or over the awareness of what has not been done on a political level may result in overly sentimental or idealized approaches to the survivor; - Anger and rage towards torturers and persecutors are expectable, but may undermine the ability to maintain objectivity when they are driven by unrecognized personal experiences and thus become chronic or excessive; - Anger or repugnance against the victim may arise as a result of feeling exposed to unaccustomed levels of anxiety. This may also arise as a result of feeling used by the victim when the clinician experiences doubt about the truth of the alleged torture history and the victim stands to benefit from an evaluation that documents the consequences of the alleged incident; - Significant differences between the cultural value systems of the clinician and the individual alleging torture may include belief in myths about ethnic groups, condescending attitudes and underestimation of the individual’s sophistication or capacity for insight. Conversely, clinicians who are members of the same ethnic group as a victim might form a non-verbalized alliance that can also affect the objectivity of the evaluation. 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 counter-transference 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 Counter-transference 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)

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 Torture survivors may have difficulties in recalling and recounting of the specific details of the torture experience and other parts of the history for several reasons Factors related with the interview conditons or communication barriers PtD Project (IRCT, HRFT, REDRESS, PHR)

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)

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)

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)

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. Factual inconsistencies over time or lack of detail in recounting a torture history are fairly common in credible cases (Herlihy et al., 2001). The symptoms resulting from torture often get in the way of orderly recall and coherent narrative (Haenel, 2001). The assessor’s attitude can also be an obstacle (Haenel, 2001). Some exaggeration or inconsistencies does not automatically invalidate a claim Response biases on questionnaires may be helpful in assessment PtD Project (IRCT, HRFT, REDRESS, PHR)

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. If possible, the investigator should ask for further clarification. These possibilities should be explored in detail. When clarification is not possible, the investigator should look for other evidence that supports or refutes the story. A network of consistent supporting details can corroborate and clarify the person’s story. Although the individual may not be able to provide the details desired by the investigator, such as dates, times, frequencies and exact identities of perpetrators, a broad outline of the traumatic events and torture will emerge and stand up over time. If, on the other hand, the clinician suspects fabrication (sometimes called “simulation”), the clinician should try to identify potential reasons for exaggeration or fabrication, keeping in mind that fabrications may require detailed knowledge about trauma-related symptoms and findings that individuals rarely possess. It may be helpful to refer the individual to another clinician for a second opinion. If the suspicion of fabrication persists, it should be documented by both clinicians. PtD Project (IRCT, HRFT, REDRESS, PHR)

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 trauma-related symptoms and findings that individuals rarely possess PtD Project (IRCT, HRFT, REDRESS, PHR)

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)

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 Interviews for medical evaluations usually begin with the clinician introducing himself or herself followed by: Explanation of the purpose of the evaluation Reviewing the conditions of the evaluation, i.e. Independence of the evaluator Confidentiality of the clincian’s findings and limits thereof Right to refuse answering questions Importance of detail and accuracy of information Acknowledge likely difficulty of recalling certain events Ability to take breaks Access to refreshments and toilet facilities Statement on the overall content of the interview including: detailed questions on events before during and after the alleged torture, followed by a physical examination, should this be the case, and the possibility of photographs Discussing the likely benefits and risks of the evaluation Addressing any questions or concerns that the individual may have Obtaining consent to proceed with the evaluation. PtD Project (IRCT, HRFT, REDRESS, PHR)

Components of the History
Psychosocial History-Pre-Arrest Past Medical/Psychological History Trauma History Review of Symptoms If possible, the interview should be designed according to the needs of the examinee: Short episodes with breaks, beginning with less sensitive issues, then probing deeper, closing the interview with a relaxing topic to ensure that the emotional arousal has subsided. 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 Psychiatric 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
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 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? As previously mentioned, an individual’s narrative account should be open-ended. In the course of eliciting a detailed history of torture and ill treatment it may be helpful for the clinician to consider possible categories of abuse. Torture methods to consider include, but are not limited to: 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 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 interviews Medical and other records Legal documents PtD Project (IRCT, HRFT, REDRESS, PHR)

Concluding 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 Referral
Assess possible therapeutic needs Clinical Social Be aware of local support services Obtain necessary consultations or examinations PtD Project (IRCT, HRFT, REDRESS, PHR)

MODULE 3 Prevention through Documentation Project

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