1. PtD Project (IRCT, HRFT, REDRESS, PHR) 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

2. Module 3 Outline Preliminary Considerations Conducting Interviews Interview Content PtD Project (IRCT, HRFT, REDRESS, PHR)

3. Module 3 Outline Preliminary Considerations Conducting Interviews Interview Content PtD Project (IRCT, HRFT, REDRESS, PHR)

4. 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)

5. 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)

6. 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)

7. 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

8. Tasks of the Interview Information gathering Emotion handling Providing Information PtD Project (IRCT, HRFT, REDRESS, PHR)

9. 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

10. 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)

11. 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)

12. 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)

13. 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

14. 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)

15. 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)

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. PtD Project (IRCT, HRFT, REDRESS, PHR) 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

24. 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

25. 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)

26. 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)

27. 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)

28. 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)

29. 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.

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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)

37. Module 3 Outline Preliminary Considerations Conducting Interviews Interview Content PtD Project (IRCT, HRFT, REDRESS, PHR)

38. Conducting Interviews Types of Questions Cognitive Techniques Summarising and Clarifying Difficulty Recalling and Recounting Assessing Inconsistencies PtD Project (IRCT, HRFT, REDRESS, PHR)

39. 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

40. 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)

41. 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)

42. 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)

43. Difficulties in Recalling and Recounting 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

44. 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

45. 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

46. 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.

47. 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

48. 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 Inconsistencies

49. 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.

50. 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 trauma- related symptoms and findings that individuals rarely possess

51. 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

52. Module 3 Outline Preliminary Considerations Conducting Interviews Interview Content PtD Project (IRCT, HRFT, REDRESS, PHR)

53. 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)

54. 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

55. Components of the History Psychosocial History-Pre-Arrest Past Medical/Psychological History Trauma History Review of Symptoms PtD Project (IRCT, HRFT, REDRESS, PHR)

56. 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)

57. 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)

58. 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)

59. 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)

60. 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)

61. 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)

62. 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)

63. 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)

64. 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)

65. 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)

66. 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)

67. 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)

68. 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)

69. Additional Sources of Information Additional interviews Medical and other records Legal documents PtD Project (IRCT, HRFT, REDRESS, PHR)

70. 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)

71. 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)