- Downloads & Materials
- Resources & Links
Module 3: Interview Considerations
According to the Istanbul Protocol, the broad purpose of the medical evaluation is to establish the facts related to alleged incidents of torture (IP, §120). The purpose of the written or oral testimony of the physician is to provide expert opinion on the degree to which medical findings correlate with the patient’s allegation of abuse and to communicate effectively the physician’s medical findings and interpretations to the judiciary or other appropriate authorities. In addition, medical testimony often serves to educate the judiciary, other government officials and the local and international communities on the physical and psychological sequelae of torture. The examiner should be prepared to do the following (IP, §121):
- Assess possible injury and abuse, even in the absence of specific allegations by individuals, law enforcement or judicial officials;
- Document physical and psychological evidence of injury and abuse;
- Correlate the degree of consistency between examination findings and specific allegations of abuse by the patient;
- Correlate the degree of consistency between individual examination findings with the knowledge of torture methods used in a particular region and their common after-effects;
- Render expert interpretation of the findings of medico-legal evaluations and provide expert opinion regarding possible causes of abuse in asylum hearings, criminal trials and civil proceedings;
- Use information obtained in an appropriate manner to enhance fact-finding and further documentation of torture.
According to the Istanbul Protocol, the broad purpose of the medical evaluation is to establish the facts related to alleged incidents of torture (IP, §120). The purpose of the written or oral testimony of the physician is to provide expert … Continue reading
If possible, the individual should be asked to give a chronological account of the incident(s) in question. Generally, open-ended questions should be used, for example: ‘Can you tell me what happened?’ or ‘Tell me more about that.’ The individual should be allowed to tell his or her story with as few interruptions as possible. Further details can be elicited with appropriate follow-up questions, such as: ‘How big was the cell?’, ‘Was there any lighting?’ and ‘How could you go to the toilet?’ Asking too many questions too quickly might confuse the individual, or even remind him or her of being interrogated.
Leading questions are avoided wherever possible, because individuals may answer with what they think the health professional wants to hear. This is especially important when interviewing for medico-legal purposes, where the testimony may be challenged in court. Closed questions, which provide the interviewee with a limited number of options and, particularly, list questions, can cause confusion in the individual and might create unnecessary inconsistencies. For example, an individual might be asked, ‘Were you arrested by the police or the army?’ limiting the answer to a choice between the two. If he or she was arrested by a special task force of soldiers and policemen working together, it would be difficult to give an accurate answer without appearing to contradict the health professional. This could in turn create inconsistencies between statements.
The pace of the interview must be dictated by the individual. Even if there is limited time for the interview (such as in a police station or prison), the interviewee should not feel rushed. It is better to focus on a few specific points than to try to cover too much ground in too little time. If there are many interviewees to be seen over several days, each should be seen once or twice for a substantial period of time, rather than several shorter sessions.
In a clinical setting, the interviewer should allow enough time between appointments to allow for this and for sufficient time to write up his or her notes. It is good practise to write up the notes of each interview at the end of that session, as various aspects of the individuals’ accounts may become confused if the interviewer attempts to write up all the interviews in a later single session, and details may be forgotten.
If possible, the individual should be asked to give a chronological account of the incident(s) in question. Generally, open-ended questions should be used, for example: ‘Can you tell me what happened?’ or ‘Tell me more about that.’ The individual should … Continue reading
- Answer: A
The primary purpose of a medical evaluation of torture and ill treatment is to assess the degree to which physical and psychological findings correlate with the individual allegations of abuse and to communicate effectively the clinician’s medical findings and interpretations to the judiciary or other appropriate authorities.
- Answer: F
Clinicians must have the capacity to create a climate of trust in which disclosure of crucial, though perhaps very painful or shameful, facts can occur. All of the considerations listed will aid clinicians in earning the trust of survivors of torture.
- Answer: C
Medical evaluations, whether for physical or psychological evidence, usually require considerable time, about 2 to 4 hours. If more time is required, it is advisable to schedule a second interview. Interviews lasting 6 hours or more may be particularly difficult for the individual being interviewed.
- Answer: D
Forensic medical services should be under judicial or an independent authority and not under the same governmental authority as the police or prison system.
- Answer: A
Physical and psychological examinations by their very nature may re-traumatise an individual by provoking and/or exacerbating psychological distress and symptoms by eliciting painful memories. The interview must be structured to minimise the risk of re-traumatisation by balancing the need to obtain detailed accurate account of events and the importance of respecting the needs of the person being interviewed.
- Answer: B
The preferred gender of the examining clinician should not be presumed. Ideally, an investigation team should contain specialists of both genders, permitting the alleged torture victim to choose the gender of the investigator and, where necessary, the interpreter.
- Answer: C
All of the statements about the use of interpreters are accurate with the exception of C. The age of the interpreter may be relevant. A young male individual may be able to discuss sexual torture with an older woman to whom he may relate as to an aunt, but not to a woman of his own age. Similarly, a young female individual may find an older man easier to talk to than one who is of a similar age to her torturer.
- Answer: A
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. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture.
- Answer: F
All of the emotional reactions listed are common counter-transference reactions that an interviewer is likely experience while listening to the interview with Sr. Diana Ortiz.
- Answer: A, B
The interviewer did not attempt to relocate the interview to a more comfortable and private location; Sr. Diana suggested that they move out of the cold weather into a nearby hotel. While the interviewer was empathetic to some extent, he maintained a somewhat detached demeanor and did not acknowledge the difficulty of recounting highly traumatic experiences.
- Answer: A
Before beginning any medical evaluation, forensic clinicians must explain their role to the individual and make clear any limits on medical confidentiality.
- Answer: A, C, D
All of the strategies listed may help to manage and limit secondary trauma with the exception of B. Discussing your emotional reactions with the survivor/alleged victim would be inappropriate and likely harmful to the individual.
- Answer: A
Inquiries should be structured to elicit an open-ended, chronological account of events experienced during detention with minimal interruptions. Closed questions are often used to add clarity to a narrative account or to carefully redirect the interview if the individual wanders off the subject. Leading questions are avoided wherever possible, because individuals may answer with what they think the health professional wants to hear.
- Answer: E
All of the techniques listed may help to improve the accuracy of information obtained in a medical evaluation.
- Answer: H
Inconsistencies may result from a number of factors that may be directly related to the torture and ill treatment or to the psychological and/or neurological symptoms that result from torture and ill treatment. Interview conditions and cross cultural factors may be significant as well. Clinicians should be familiar with such factors to effectively explain any inconsistencies observed.
- Answer: F
All of the steps listed may help clinicians to assess inconsistencies that may be identified in the course of a medical evaluation of torture and ill treatment.
- Answer: B
Inquiries into prior political activities and beliefs and opinions are relevant insofar as they help to explain why the person was detained and/or tortured, but such inquiries are best made indirectly by asking the person what accusations were made, or why they think they were detained and tortured. The psychosocial history is particularly important in understanding the meaning that individuals assign to traumatic experiences.
- Answer: A
Correlations between specific allegations of abuse and subsequent physical evidence require clinicians to obtain detailed information for each form of abuse alleged as stated in the question.
- Answer: B
A medico-legal report should not be falsified under any circumstance. The ethical obligation of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain professional credibility which, in turn, benefits survivors of torture. A medico-legal report should not be falsified under any circumstance.
- Answer: A
Wherever possible, examinations to document torture for medico-legal purposes should be combined with an assessment for other needs, whether referral to specialist physicians, psychologists, physiotherapists or those who can offer social advice and support. Investigators should be aware of local rehabilitation and support services. Those who appear to be in need of further medical or psychological care should be referred to the appropriate services.
Answer: A The primary purpose of a medical evaluation of torture and ill treatment is to assess the degree to which physical and psychological findings correlate with the individual allegations of abuse and to communicate effectively the clinician’s medical findings … Continue reading
Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to ensure that they do not place the detainee in danger (or in additional difficulty). Promises must not be made, for example, to provide security for the witness or for relatives who might be at risk, unless the interviewer is certain that they can be fulfilled. Witnesses might believe that international organisations or others investigating allegations of torture have more power to protect them than is the case. It is part of the informed consent process that individuals are aware of all the issues before they agree for a clinician to make a formal report. If the risk of harm from reprisals is a virtual certainty, conducting a medical evaluation may be considered unethical even if informed consent is obtained. This may be the case in the context of documenting human rights violations in places of ongoing conflict.
Whether or not certain questions can be asked safely will vary considerably and depends on the degree to which confidentiality and security can be ensured. When necessary, questions about forbidden activities should be avoided.
If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention, but rather should appear before the prosecutor or judge to determine the detainee’s legal disposition (see Procedural Safeguards below).
An interviewer will make notes of the interview, and may use other recording devices. The reasons for this should be explained to the interviewee who should be reassured as to how the notes and other records will be used and asked for consent. The way in which any records of such interviews are stored can be important in protecting the security of the interviewer and the interviewee. In many countries where torture is prevalent, the police have been known to raid clinics and search or confiscate medical records. In order to protect patients, therefore, in such conditions records should have no obvious identifying information on any document inside (such as initials or date of birth), and the files themselves being numbered with a register kept in a secure place elsewhere. Patients can be given cards with the identifying number so that treatment can be continued even if the register is not available. In some circumstances it may be necessary to hold records at a different location or even in a third country to ensure their security.
If information about an individual needs to be transmitted to another body, fax transmission is generally safer than e-mail as a copy of the latter may be stored on the sending computer or held on the server of the internet service provider. In some countries the authorities routinely screen all outgoing messages.
Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to … Continue reading
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 clinician’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.
For forensic evaluations, the clinician should establish the identity of the subject. As previously mentioned, law enforcement officials should not be present during the evaluation. If such officials refuse to leave the examination room, it should be noted in the clinician’s report or and/or the evaluation may be cancelled.
When the medical evaluation is being conducted by more than one clinician, i.e. one for physical evidence and another for psychological evidence, the content of the interview should focus on the information most relevant to their expertise.
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 clinician’s findings and limits … Continue reading
The documentation of torture and other ill-treatment depends on the gathering of detailed and accurate information from the individual on the circumstances of the alleged events, including details of any arrest, detention, conditions of detention and specific treatment while under interrogation. The interview should be structured and conducted according to the guidelines defined in “the general considerations for the interview”, “procedural safeguards” and “medical ethics” chapters of the Istanbul Protocol. These considerations apply to all persons carrying out interviews whether they are lawyers, medical doctors, psychologists, psychiatrists, human rights monitors or members of any other profession. Interview considerations that pertain specifically to the documentation of physical and psychological evidence of torure are included in Modules 5 and 6 respectively.
Torture is usually both physical and psychological in nature. It is important, therefore, for each clinician to elicit and relate physical and psychological information in their evaluations. It should be noted that, with appropriate training, physicians may become qualified to conduct psychological evaluations. Those who are not qualified, should refer the alleged victim to a qualified psychological expert (i.e. psychologist, psychiatrist, clinical social worker). Medical doctors should carefully consider the potential benefits and possible difficulties of qualifying as a psychological expert. It may be helpful to seek the advice of attorneys to better understand country-specific requirements to qualify as an expert witness on on psychological evidence of torture.
The degree of detail gathered during an interview with an alleged victim of torture depends on several factors, such as the aim of the interview/examination (producing a note in a medical record of incidental findings during a routine medical visit, versus being asked to provide a medical report for a judicial body), the location and circumstances of the interview (for example in a health clinic, in a police station or prison, or in a rehabilitation centre for survivors of torture) and the degree of access to the individual and amount of time available. This being said, the principles on interviewing can be adapted and applied to the various circumstances in which an individual alleging torture may be encountered.
Clinicians should not assume that the individual, such as the asylum applicant’s attorney, requesting a medico-legal evaluation has related all the material facts. It is the clinician’s responsibility to discover and report upon any material findings that he or she considers relevant, even if they may be considered irrelevant or adverse to the case of the party requesting the medical examination. Findings that are consistent with torture or other forms of ill-treatment must not be excluded from a medico-legal report under any circumstance.
The documentation of torture and other ill-treatment depends on the gathering of detailed and accurate information from the individual on the circumstances of the alleged events, including details of any arrest, detention, conditions of detention and specific treatment while under … Continue reading
Medical evaluations of torture allegations should be conducted at a location that the clinician deems most suitable. The clinician should ensure that the interviewee, particularly if the interviewee is a detainee, is not forced into accepting a place which is not comfortable and safe. In many situations it is not possible to control the environment of the interview (for example in police stations and prisons), and the interviewer will have to make the best of less than ideal conditions. However, the basic principles on interviewing should be adapted and applied as far as possible to the different contexts. The clinician should make sure to explore all opportunities to establish a setting which is as private, safe and comfortable as possible. Attention should be paid to arrange the room in a way that it is not reminiscent of an official surrounding and the process of interrogation.
Sufficient time should be allotted for the interview and arranged in advance. A twoto-four hour interview may be insufficient to conduct an evaluation for physical or psychological evidence of torture. A second, and possibly a third, interview may be needed to be scheduled to complete the evaluation. If the evaluation is taking place under time constraints, the information gathered and the outcome of the interview might be limited. Such constraints and limitations should be noted in a medical evaluation.
- The room should have appropriate physical conditions (light, ventilation, size, temperature).
- There should be access to toilet facilities and refreshment opportunities. It would be good to have water and tissues within the reach of the interviewee.
- 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 clearly.
Medical evaluations of torture allegations should be conducted at a location that the clinician deems most suitable. The clinician should ensure that the interviewee, particularly if the interviewee is a detainee, is not forced into accepting a place which is … Continue reading
Psychological research has shown that the ability to recall important incidents can be enhanced by using some basic cognitive techniques. Having established rapport with the individual, he or she should be allowed to give a free narrative about the events. The interviewer should allow the individual, as much as possible, the time to describe what happened in his or her own words. Clarification of points is permissible but not direct questioning which might break the individual’s recall. Only after the individual has finished his or her narrative should direct questions be asked to clarify points. The survivor of torture should know that it is acceptable to say: ‘I don’t understand the question,’ or ‘I don’t know the answer.’
The quality of the information gained can be improved by some specific techniques. Firstly, in a clinical setting in which time allows it, the individual should be told to describe everything surrounding the time of ill-treatment (for instance describing the events and process of being taken into detention), even if it does not appear directly relevant to him or her. This might relate to events that could be more important than the individual realises. Secondly, as he or she relates them, this can bring other events that are more relevant into his or her mind. It helps if he or she is encouraged to recall the context in which the events happened.
Having encouraged the interviewee to describe the events in a free narrative, in chronological order, the interviewer can seek more detail by asking questions in a different order. For example, by reversing the order: ‘You were telling me …, what happened just before that?’
Another tool is changing the perspective, which means trying to describe the events from another point of view, for example if the interviewee is sufficiently well-educated the interviewer could ask: ‘How would a tailor describe what the man was wearing?’ or ‘When you were arrested at the demonstration, what would a spectator have seen?’
It is important to remember that different cultures have different concepts of what is normal behaviour in an interview. In some societies it is considered polite not to look directly into the eyes of someone in a position of relative authority (such as an interviewer), whereas in other cultures such behaviour is considered to be a sign of dishonesty. People from some cultures find constant hand movements a normal part of communication, whereas those from others find them distracting. Personal space varies between and within cultures, and what might be normal between colleagues could feel too close in an interview setting. This could make the individual feel anxious, and behave in a way that the interviewer perceives as uncooperative.
Psychological research has shown that the ability to recall important incidents can be enhanced by using some basic cognitive techniques. Having established rapport with the individual, he or she should be allowed to give a free narrative about the events. … Continue reading
The examiner should inquire into the person’s daily life, relations with friends and family, work/school, occupation, interests, and use of alcohol and drugs, prior to the traumatic events. Inquiries into prior political activities and beliefs and opinions are relevant insofar as they help to explain why the person was detained and/or tortured, but such inquiries are best made indirectly by asking the person what accusations were made, or why they think they were detained and tortured. The psychosocial history is particularly important in understanding the meaning that individuals assign to traumatic experiences.
The occupation of the individual is sometimes relevant to the documentation of torture because it might affect the differential diagnosis of any lesions. Occupation can also be a marker of educational attainment, and so can be evidence of a change in cognitive and/or psychosocial functioning. Statements from former colleagues, or documentation of work appraisals, can act as corroboration of this point.
The social background can also be relevant. If the individual has some educational achievements documented, these can be used as indicators of the premorbid intellectual state (the psychological condition the individual was in prior to the trauma). They can then be compared with the evaluation of the individual’s present level of functioning, and judgements can be made about changes, and any possible causation.
The examiner should inquire into the person’s daily life, relations with friends and family, work/school, occupation, interests, and use of alcohol and drugs, prior to the traumatic events. Inquiries into prior political activities and beliefs and opinions are relevant insofar … Continue reading