ptd project (irct, hrft, redress, phr) module 3 prevention through documentation project interview...

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


Preliminary ConsiderationsPreliminary Considerations

– Purpose of medical evaluations

– Interview settings

– Trust

– Informed consent and Confidentiality

– Privacy

– Empathy and Objectivity

– Safety and security


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


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



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



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


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



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)


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


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



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.


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


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


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


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


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


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.


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


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


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


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


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



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.


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


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


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


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


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


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





Interview Content


Conducting InterviewsConducting Interviews

Types of QuestionsCognitive TechniquesSummarising and ClarifyingDifficulty Recalling and RecountingAssessing Inconsistencies



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


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)


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



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



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



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



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.



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


!!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



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 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


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




Interview Content


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



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


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


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


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


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?


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


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?


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


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


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?


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)


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


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.


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


Additional Sources of Additional Sources of InformationInformation

Additional interviews

Medical and other records

Legal documents


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


Considerations for ReferralConsiderations for Referral

Assess possible therapeutic needs– Clinical– Social

Be aware of local support servicesObtain necessary consultations or

examinations


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