Module 3: Interview Considerations

Module 3: Interview Considerations

Objectives

  • To understand the key role of the interview in conducting medical evaluations of torture allegations
  • To be familiar with conditions necessary for an effective interview
  • To understand and develop interview process skills such as empathy and earning trust
  • To learn effective and appropriate techniques of questioning
  • To understand the effect of the interviewing style on the interview process and the alleged victim
  • To develop the capacity to elicit a detailed narrative account of alleged experiences
  • To be familiar with possible difficulties of recalling and recounting elements of torture experiences
  • To understand how and why difficulties may arise during an interview
  • To be familiar with possible transference and counter-transference reactions
  • To develop awareness to possible vicarious traumatisation and burnout and discuss strategies to address their effects
  • To examine individual reactions to hearing a recording of an interview with a survivor of torture

Content

  • Preliminary Considerations
    • Purpose of medical evaluations
    • Interview settings
    • Trust
    • Informed consent
    • Confidentiality
    • Privacy
    • Empathy
    • Objectivity
    • Safety and security
    • Procedural Safeguards for Detainees
    • Risk of Re-traumatisation
    • Gender Considerations
    • Interviewing Children
    • Cultural and Religious Awareness
    • Working with Interpreters
    • Transference and Counter-Transference Reaction
  • Conducting Interviews
    • Types of Questions
    • Cognitive Techniques
    • Summarising and Clarifying
    • Difficulties Recalling and Recounting
    • Assessing Inconsistencies
  • 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

Discussion Topics

  • Play audio (MP3 file [2] [1]) of National Public Radio interview with Sr. Dianna Ortiz (about 15 minutes) and discuss relevant interview considerations: confidentiality, informed consent, privacy, safety, objectivity, impartiality, creating a climate of trust, courtesy, honesty, empathy, the effects of interviewing style, appropriate use of open-ended and closed questioning, the risks of re-traumatisation and how to minimize the risk of re-traumatisation.
  • Discuss individual responses to the interview with Sr. Dianna Ortiz and discuss strategies for managing such reactions and limiting secondary trauma and “burn-out”
  • Discuss what you find most challenging about interviewing survivors of torture and ill treatment

Teaching Formats

  • Group Activity:
    • Listen to the audio (MP3 file [2] [1]) of National Public Radio interview with Sr. Dianna Ortiz (about 15 minutes) as a class.
    • Divide the class into several groups and have each group address the first two Discussion Topics above
    • A facilitator should be identified to moderate the discussion and rapporteur should be identified to record the group’s findings and report them when the class reconvenes.
    • After 20-30 minutes of group discussion, the entire class should reconvene
    • Rapporteurs should briefly report on their group’s findings
    • Open class discussion
  • Individual Research/Assignment:
    • Research ways in which clinicians who work with survivors of torture deal with secondary trauma. Write a series of recommendations for colleagues who conduct medical evaluations of alleged torture victims on a regular basis, but are unaware of counter-transference issues
  • Journal Entry: (Instructor to assign Write a few paragraphs — no more than a page)
    • Consider your response to the audiotape of interview with Sr. Dianna Ortiz. Provide a series of recommendations to effectivel address these reactions and possibly others.
    • Discuss what you find most challenging about interviewing survivors of torture and ill treatment

Primary Resources

  • The Istanbul Protocol
  • The Medical Documentation of Torture
  • Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
  • Psychological Evaluation of Torture Allegations: An International Training Manual
  • Audio of interview with Sr. Dianna Ortiz [3]. National Public Radio. 1996.
  • Trainers’ Guidelines for Health Professionals: Training of Users
  • Torture Reporting Handbook, Part II – Documenting Allegations

Objectives To understand the key role of the interview in conducting medical evaluations of torture allegations To be familiar with conditions necessary for an effective interview To understand and develop interview process skills such as empathy and earning trust To … 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

Prison/Detention Place Conditions

Include access to and descriptions of food and drink, toilet facilities, lighting, temperature, ventilation. Also, document any contact with family, lawyers or health professionals, conditions of overcrowding or solitary confinement, dimensions of the detention place, and whether there are other people who can corroborate his/her detention. Consider the following questions: What happened first? Where were you taken? Was there an identification process (personal information recorded, fingerprints, photographs)? Were you asked to sign anything? Describe the conditions of the cell/room (note size, others present, light, ventilation, temperature, presence of insects, rodents, bedding, and access to food, water and toilet). What did you hear, see and smell? Did you have any contact with people outside, or access to medical care? What was the physical layout of the place where you were detained?

Include access to and descriptions of food and drink, toilet facilities, lighting, temperature, ventilation. Also, document any contact with family, lawyers or health professionals, conditions of overcrowding or solitary confinement, dimensions of the detention place, and whether there are other … Continue reading

Privacy

Examinations must be conducted in private under the control of the clinician. Privacy during the interviews is not only necessary for ethical reasons, but also when talking about sensitive issues that may be embarrassing or shameful for the person being evaluated. The clinician should establish and maintain privacy during the entire interview (IP, §83, 124). Police or other law enforcement officials should never be present in the examination room. The presence of police officers, soldiers, prison officers or other law enforcement officials in the examination room, for whatever reason, should be noted in the clinician’s report. Their presence during the examination may be grounds for disregarding a negative medical report (IP, §124, 125). If any other persons are present in the interview room during the interview, the identity, titles, affiliations of those persons should be indicated in the report (IP, §125).

Examinations must be conducted in private under the control of the clinician. Privacy during the interviews is not only necessary for ethical reasons, but also when talking about sensitive issues that may be embarrassing or shameful for the person being … Continue reading

Empathy

Empathy and human contact may be the most important thing that people still in custody receive from the investigator. The investigation itself may contribute nothing of specific benefit to the person being interviewed, as in most cases their torture will be over. The meagre consolation of knowing that the information may serve a future purpose will however be greatly enhanced if the investigator shows appropriate empathy. While this may seem self-evident, all too often investigators in actual prison visits are so concerned about obtaining information that they fail to empathize with the prisoner being interviewed.

Empathy and human contact may be the most important thing that people still in custody receive from the investigator. The investigation itself may contribute nothing of specific benefit to the person being interviewed, as in most cases their torture will … Continue reading

Allegations of Torture and Ill-treatment

The interviewer should then take a detailed description of specific methods of ill-treatment employed during periods ofquestioning, interrogation or indeed at any time while they are in the control of the authority. It cannot be over-emphasised that it is not sufficient to document only physical ill-treatment and any resulting injuries or scars. Psychological methods must also be accurately noted since these will often produce both psychological reactions and physical symptoms.

In obtaining historical information on torture and ill-treatment, one should be cautious about suggesting forms of abuse that a person may have been subjected to. This may help to separate potential embellishment from valid experiences. However, eliciting negative responses to questions about various forms of torture also may help to establish the credibility of the interviewee.

Questions should be designed to elicit a coherent narrative account. Consider the following questions: Where did the abuse take place, when and for how long? Could you see? Why not? Before discussing forms of abuse, note who was present (give names, positions). Describe the room/place. What objects did you observe? If possible, describe each instrument of torture in detail; for electrical torture, the current, device, and number and shape of electrodes. Ask about clothing/disrobing/change of clothing. Record quotations of what was said during interrogation, insults to one’s identity, etc. What was said among the perpetrators?

For each form of abuse note: body position/restraint, nature of contact, including duration, frequency, anatomical location, and the area of the body affected. Was there any bleeding, head trauma, or loss of consciousness? Was the loss of consciousness due to head trauma, asphyxiation, or pain? One should also ask about how was the person’s condition at the end of the “session.” Could he or she walk? Did s/he have to be helped back or carried back to the cell? Could s/he get up the next day, eat, use the toilet, or walk up or down stairs? How long did the feet stay swollen? All this gives a certain completeness to the description, which a “check list” of methods does not.

Asking detailed questions about specific torture allegations will aid physicians in their efforts to assess correlations between allegations of abuse and presence or absence of medical findings. For example, questions related to allegations of suspension may include: the duration and frequency of the alleged torture (Note: time estimates are subjective, and may not be accurate since disorientation of time and place are common effects of torture), a description of the form of suspension (“crucifixion,” Palestinian,” etc.), the use of cloth restraints vs. rope, wire or other material, whether weights or pulling was used to increase the pain of the suspension, and whether there was any loss of consciousness, or any other acute or chronic symptoms or disabilities. Such details may be critical in corroborating physical evidence and allegations. For example, a history of brief or partial suspension (some of the individual’s weight supported by his/her feet) with the use of non-abrasive cloth restraints may help to explain the absence of any acute or chronic physical findings on examination. Alternatively, allegations of prolonged and repeated “Palestinian” using ropes would be highly consistent with evidence of a brachial plexus injury and circumferential wrist abrasions on examination.

In order to assess psychological evidence of torture, it is important for the clinician to assess thought content, affect, and psychological symptoms during and after the period of detention (see Module 6).

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. A survivor may have forgotten, for instance, that he or she was subjected to a mock execution. The following list of torture methods is not meant to be used by clinicians as a “check list”, nor as a model for listing torture methods in a report. A method-listing approach may be counterproductive, as the entire clinical picture produced by torture is much more than the simple sum of lesions produced by methods on a list. Furthermore, it is important to recognise that the distinction between physical and psychological methods is artificial.

Torture methods to consider include, but are not limited to:

  • Blunt trauma, such as a punch, kick, slap, whipping, a beating with wires or truncheons or falling down;
  • Positional torture, using suspension, stretching limbs apart, prolonged constraint of movement, forced positioning;
  • Burns with cigarettes, heated instruments, scalding liquid or a caustic substance;
  • Electric shocks;
  • Asphyxiation, such as wet and dry methods, drowning, smothering, choking or use of chemicals;
  • Crush injuries, such as smashing fingers or using a heavy roller to injure the thighs or back;
  • Penetrating injuries, such as stab and gunshot wounds, wires under nails;
  • Chemical exposure to salt, chili pepper, gasoline, etc. (in wounds or body cavities);
  • Sexual violence to genitals, molestation, instrumentation, rape;
  • Crush injury or traumatic removal of digits and limbs;
  • Medical amputation of digits or limbs, surgical removal of organs;
  • Pharmacological torture using toxic doses of sedatives, neuroleptics, paralytics, etc.;
  • Conditions of detention:
    • Such as a small or overcrowded cell
    • Solitary confinement
    • Unhygienic conditions
    • No access to toilet facilities
    • Irregular or contaminated food and water
    • Exposure to extremes of temperature
    • Denial of privacy
    • Forced nakedness
  • Deprivation of:
    • Normal sensory stimulation, such as sound, light, sense of time, isolation, manipulation of brightness of the cell,
    • Physiological needs, restriction of sleep, food, water, toilet facilities, bathing, motor activities, medical care,
    • Social contacts, isolation within prison, loss of contact with the outside world (victims are often kept in isolation in order to prevent bonding and mutual identification and to encourage traumatic bonding with the torturer);
  • Humiliation, such as verbal abuse, performance of humiliating acts;
  • Threats of death, harm to family, further torture, imprisonment, mock executions;
  • Threats of attack by animals, such as dogs, cats, rats or scorpions;
  • Psychological techniques to break down the individual, including forced “betrayals,” learned helplessness, exposure to ambiguous situations or contradictory messages;
  • Violation of taboos;
  • Behavioural coercion, such as:
    • Forced engagement in practises against the religion of the victim (e.g. forcing Muslims to eat pork)
    • Forced harm to others through torture or other abuses
    • Forced destruction of property
    • Forced betrayal of someone placing them at risk of harm;
  • Forcing the victim to witness torture or atrocities being inflicted on others.

The above examples do not by any means constitute a definitive list. There are many other forms of abuse that have been witnessed in the past, and there will probably be new forms in the future. International definitions of torture deliberately avoid providing a list of methods that are seen as torture. One of the reasons for this is that such a list may imply that it is exhaustive, and those engaged in such practises would simply devise methods that do not appear on the list, in an attempt to circumvent the definition. Torture is a complex phenomenon; it cannot be simply reduced to a list of acts.

A review of common torture methods and their physical and psychological sequelae is included in Module 4.

The interviewer should then take a detailed description of specific methods of ill-treatment employed during periods ofquestioning, interrogation or indeed at any time while they are in the control of the authority. It cannot be over-emphasised that it is not … Continue reading

Objectivity

Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain the professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician should communicate their understanding of the individual’s pain and suffering and adopt a supportive, non-judgmental approach. Clinicians need to be sensitive and empathic in their questioning while remaining objective in their clinical assessment.

Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain the professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician … Continue reading

Review of Symptoms

After eliciting a detailed narrative of the alleged torture and ill-treatment, it is important to document subsequent symptoms and disabilities that may be related to the alleged abuse. The clinician should obtain a detailed review of physical and psychological symptoms and disabilities at the time of the abuse and subsequently, up to the present time. All complaints of the alleged torture victim are of significance; although there may or may not be a correlation with the physical findings, they should be reported. Acute and chronic symptoms and disabilities associated with specific forms of abuse and the subsequent healing processes should be documented. Specific information acute and chronic symptoms and disabilities are included in Module 5 (Physical Evidence of Torture) and Module 6 (Psychological Evidence of Torture).

After eliciting a detailed narrative of the alleged torture and ill-treatment, it is important to document subsequent symptoms and disabilities that may be related to the alleged abuse. The clinician should obtain a detailed review of physical and psychological symptoms … Continue reading

Safety and Security

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