Module 3: Interview Considerations

Summarising and clarifying

During the interview, it is often helpful to clarify points, in order to ensure that the information is accurate. For example: ‘When you say that you were suspended by your arms, in what position were they?’ Alternatively the individual can be asked to recreate the position, but it should be borne in mind that doing so could provoke uncomfortable feelings or other reactions in the individual.

At the end of each session, it generally helps to summarise the key points, to ensure that they are clear. This sometimes has the additional benefit of getting the individual to remember details that add to the narrative.

In medico-legal cases, it may be helpful to have an opportunity to meet with the individual again to review any questions or inconsistancies. This also provides an opportunity to follow up any clinical problems that may have been identified in the evaluation.

During the interview, it is often helpful to clarify points, in order to ensure that the information is accurate. For example: ‘When you say that you were suspended by your arms, in what position were they?’ Alternatively the individual can … Continue reading

Interview Content

Past Medical History

Obtain a complete medical history, including prior medical, surgical and/or psychiatric problems. Be sure to document any history of injuries before the period of detention and any possible after-effects. Knowledge of prior injuries may help to differentiate physical findings related to torture from those that are not.

Obtain a complete medical history, including prior medical, surgical and/or psychiatric problems. Be sure to document any history of injuries before the period of detention and any possible after-effects. Knowledge of prior injuries may help to differentiate physical findings related … Continue reading

Trust

Trust is an essential component of eliciting an accurate account of abuse. Earning the trust of someone who has experienced torture or other forms of abuse requires active listening, meticulous communication, courtesy and genuine empathy and honesty. 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. It is important to be aware that those facts are sometimes intimate secrets that the person may reveal at that moment for the first time.

Clinicians should explain what to expect in the evaluation. The clinician should also be mindful of the tone, phrasing and sequencing of questions (sensitive questions should be asked only after some degree of rapport has been developed) and should acknowledge the interviewee’s ability to take a break if needed or to choose not to respond to any question.

Trust is an essential component of eliciting an accurate account of abuse. Earning the trust of someone who has experienced torture or other forms of abuse requires active listening, meticulous communication, courtesy and genuine empathy and honesty. Clinicians must have … Continue reading

Informed Consent

Clinicians must ensure that informed consent is based on adequate disclosure and understanding of the potential benefits and adverse consequences of a medical evaluation and that consent is given voluntarily without coercion by others, particularly law enforcement or judicial authorities. The interviewee has the right to refuse the evaluation. In such circumstances, the clinician should document the reason for refusal of an evaluation. According to the Istanbul Protocol:

Medical experts involved in the investigation of torture or ill-treatment shall behave at all times in conformity with the highest ethical standards and, in particular, shall obtain informed consent before any examination is undertaken.

— (Istanbul Principle 6(a))

From the outset, the alleged victim should be informed of: the nature of the process, why his/her evidence is being sought, how the information given by the person would be used and possible consequences.

As stated in Module 2, 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 that may be imposed by State or judicial authorities.
  • Understands the information provided
  • Gives his/her consent voluntarily
  • Provides authorisation for his/her consent

Clinicians must ensure that informed consent is based on adequate disclosure and understanding of the potential benefits and adverse consequences of a medical evaluation and that consent is given voluntarily without coercion by others, particularly law enforcement or judicial authorities. … Continue reading

Difficulties Recalling and Recounting

Torture survivors may have difficulties in recalling and recounting the specific details of the torture experience and other parts of the history for several important reasons. Clinicians should be familiar with such factors as they commonly manifest as inconsistencies in the interview. Difficulty recalling and recounting may be related to:

  • Factors directly related to the torture experience
    • Factors during torture itself, such as blindfolding, drugging, lapses of consciousness, etc.
    • Disorientation in time and place during torture due to the nature of torture or extreme stress experienced during torture.
    • Neuro-psychiatric memory impairment resulting from head injuries, suffocation, near drowning, starvation, hunger strikes or vitamin deficiencies.
    • Experiencing repeated and similar events may also lead to difficulties in recalling clearly the details of specific events.
  • Factors related to the psychological impact of torture
    • PTSD-related memory disturbances recalling the traumatic event or intrusive memories, nightmares and the inability to remember important details of the event.
    • Denial and avoidance, which can be protective coping mechanisms, in these particular circumstances.
    • High emotional arousal and impaired memory secondary to trauma-related mental illnesses, such as depression and post-traumatic stress disorder.
    • Other psychological symptoms such as concentration difficulties, fragmentation or repression of traumatic memories, confusion, dissociation, amnesia.
    • Feelings of guilt or shame.
  • Cultural factors
    • 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 interview conditions or barriers of communication
    • Fear of placing oneself or others at risk.
    • Lack of trust in the examining clinician and/or interpreter.
    • Lack of feeling safe during the interview.
    • Environmental barriers such as lack of privacy, comfort of interview setting, inadequate time for the interview.
    • Physical barriers such as pain or other discomforts, fatigue, sensory deficits.
    • Socio-cultural barriers such as the gender of the interviewer, language and cultural differences.
    • Barriers due to transference/counter-transference reactions during the interview.
    • Inadequately conducted and/or poorly structured interviews.

Torture survivors may have difficulties in recalling and recounting the specific details of the torture experience and other parts of the history for several important reasons. Clinicians should be familiar with such factors as they commonly manifest as inconsistencies in … Continue reading

Module 3 Presentation: Interview Considerations


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Summary of Detention(s) and Abuse

Before obtaining a detailed account of events, elicit summary information, including dates, places, duration of detention, frequency and duration of torture sessions. A summary will help to make effective use of time. In some cases where survivors have been tortured on multiple occasions, they may be able to recall what happened to them, but often can not recall exactly where and when each event occurred. In such circumstances, it may be advisable to elicit the historical account by methods of abuse rather than as a series of events during specific arrests.

Similarly, in taking a history it may often be useful to have “what happened where” documented as much as possible. “Holding places” are often operated by different security/police/armed forces, and what events happened in different places may be useful to get a full picture of the torture system. Obtaining a map of where the torture occurred may be useful in piecing together different histories from different people. This will often prove very useful for the overall evaluation.

Before obtaining a detailed account of events, elicit summary information, including dates, places, duration of detention, frequency and duration of torture sessions. A summary will help to make effective use of time. In some cases where survivors have been tortured … Continue reading

Confidentiality

Clinicians have a duty to maintain confidentiality of information and to disclose information with only the interviewee’s informed consent. The clarification of confidentiality and its limits are of paramount importance for a well-conducted interview. The interviewee should be clearly informed of any limits on the confidentiality of the evaluation and of any legal obligations for disclosure of the information gathered by means of the interview and medical/psychological examination at the beginning of the interview.

Individuals may fear that information revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture. In many circumstances, the evaluator will be a member of the majority culture and ethnicity, whereas the patient, in the situation and location of the interview, is likely to belong to a minority group or culture. This dynamic of inequality may reinforce the perceived and real imbalance of power and may increase the potential sense of fear, mistrust and forced submission in the interviewee.

Clinicians have a duty to maintain confidentiality of information and to disclose information with only the interviewee’s informed consent. The clarification of confidentiality and its limits are of paramount importance for a well-conducted interview. The interviewee should be clearly informed … Continue reading

Self-Assessment and Quiz

  1. 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 individual allegations of abuse.
    1. True
    2. False
  2. Which of the following will aid clinicians in earning the trust of individuals who have experienced torture and ill treatment?
    1. Active listening
    2. Meticulous communication
    3. Courtesy, genuine empathy and honesty
    4. Explaining what to expect in the evaluation
    5. Being mindful of the tone, phrasing and sequencing of questions (sensitive questions should be asked only after some degree of rapport has been developed)
    6. All of the above
  3. Clinicians planning to conduct a medical evaluation for physical or psychological evidence of torture and ill treatment should schedule adequate time:
    1. About 30 minutes
    2. About 1 hours
    3. About 2 to 4 hours
    4. More than 6 hours
  4. Which of the following is not a procedural safeguard according to the Istanbul Protocol?
    1. It is mandatory that detainees undergo a preliminary medical examination at the time of detention; a further examination and evaluation should be made upon their release.
    2. The officials who supervise the transportation of the detainee should be responsible to the public prosecutors and not to other law enforcement officials.
    3. The medical examination for detainees should be free of charge.
    4. Forensic medical services should be under the authority of the police or prison system.
    5. Detainees have the right to obtain a second or alternative medical evaluation by a qualified physician during his/her detention.
  5. Clinicians must balance two important requirements in the course of interviewing individuals who allege torture and ill treatment: 1) the need to obtain a detailed accurate account of events, and 2) the importance of respecting the needs of the person being interviewed.
    1. True
    2. False
  6. The gender of the examining clinician should always be the same as the interviewee.
    1. True
    2. False
  7. Which of the following are not accurate statements about the use of interpreters for medical evaluations of torture and ill treatment?
    1. As a rule, family members should not be used
    2. In cases of alleged sexual assault of a woman it is advisable to use a female interpreter if the interviewee does not express a gender preference
    3. The age of the interviewer does not matter
    4. Interviewers should make eye contact with and speak directly to the interviewee
    5. There may be difficulties when the interviewee and the interpreter are from different, ethnic, religious, social, and/or political backgrounds
  8. When a physician is involved in the torture of an individual, he or she may have difficulty trusting the examining clinician. This is an example of:
    1. Transference
    2. Counter-transference
    3. A reaction formation
    4. Traumatic delusion
  9. After listening to the audiotape of the 1996 National Public Radio interview with Sr. Diana Ortiz, consider which of the following emotional reactions that an interviewer is likely to have:
    1. Anger
    2. Helplessness
    3. Fear
    4. Shame
    5. Guilt
    6. All of the above
  10. After listening to the audiotape of the 1996 National Public Radio interview with Sr. Diana Ortiz, identify interview considerations that the interviewer did not adequately address:
    1. Comfort and privacy
    2. Empathy
    3. Appropriate use of open-ended and closed questioning
    4. Allowing the interviewee to have some control over the interview process
    5. All of the above
  11. Before a forensic interview begins, the clinician must inform the interviewee of any limits on the confidentiality of the information he or she provides.
    1. True
    2. False
  12. As a clinician who provides care to survivors of torture and/or conducts medical evaluations of alleged victims of torture and ill treatment, what strategies do you consider to be effective in managing and limiting secondary trauma and “burn out?”
    1. Debriefing with colleagues and seeking counseling if needed
    2. Discussing your emotional reactions with the survivor/alleged victim
    3. Limiting your exposure to traumatic cases
    4. Awareness to, reflection on and modulation of your emotional reactions to interviews with survivors of torture and ill treatment
    5. All of the above
  13. Initially, interview questions should be open-ended, allowing a narration of the trauma with minimal interruptions.
    1. True
    2. False
  14. The accuracy of information obtained in a medical evaluation can be improved by:
    1. Clarifying details
    2. Summarising key points periodically
    3. Scheduling a follow-up interview to address outstanding questions or any inconsistencies
    4. Using cognitive techniques such as “You were telling me about being suspended; can you tell me what happened just before that?”
    5. All of the above
  15. Which of the following may affect an individual’s ability to recall and recount torture and ill treatment?
    1. Disorientation during torture, blindfolding, drugging, and lapses of consciousness
    2. Neurological or psychological memory disturbances
    3. Feelings of guilt or shame
    4. Cultural differences in the perception of time
    5. Lack of trust in the examining clinician and/or interpreter
    6. Fear of reprisals
    7. Lack of privacy during the interview
    8. All of the above
  16. Which of the following are appropriate steps for clinicians to take to assess inconsistencies?
    1. Ask the individual for further clarification
    2. Identify other sources of corroborating information
    3. Identify possible reasons for exaggeration or fabrication
    4. Schedule an additional interview to discuss inconsistencies
    5. Refer the individual to another clinician for a second opinion
    6. All of the above
  17. In medical evaluations of torture and ill treatment it is not appropriate to ask questions about prior political activities and/or social beliefs and attitudes?
    1. True
    2. False
  18. In obtaining information on specific methods of torture and ill-treatment, the clinician should note for each form of abuse: body position, methods of restraint, nature of contact, the duration, frequency, and anatomical location of the alleged abuse, and the subsequent effects of the alleged abuse, i.e. pain, bleeding, loss of consciousness, disabilities, etc.
    1. True
    2. False
  19. The ethical principles of beneficence and non-malfeasance require that clinicians’ conclusions regarding torture and ill treatment be consistent with the least harmful legal outcome.
    1. True
    2. False
  20. In the course of documenting medical evidence of torture and ill-treatment, physicians have an ethical duty of identifying and making appropriate referrals for medical and social needs.
    1. True
    2. False

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 individual allegations of abuse. True False Which of the following will aid clinicians in earning … Continue reading