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Working with Interpreters
Conducting Interviews
Toolkits > Istanbul Protocol Model Medical Curriculum > Module 3: Interview Considerations > Preliminary Considerations > Transference and Counter-Transference Reactions

Transference and Counter-Transference Reactions

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Clinicians who conduct physical and psychological evaluations should be aware of the potential emotional reactions that evaluations of severe trauma may elicit in the interviewee and interviewer. These emotional reactions are known as transference and countertransference.

Transference

Transference refers to the feelings a survivor has towards the clinician that relate to past experiences but which are misunderstood as directed towards the clinician personally. Common transference considerations may include the following:

  • A clinical interview may induce mistrust on the part of the torture survivor and possibly remind him or her of previous terrogations thereby “re-traumatizing” him or her. To reduce the effects of re-traumatisation, the clinician should communicate a sense of empathy and understanding.
  • The survivor may suspect the clinician of having voyeuristic and sadistic motivations or may have prejudices towards the clinician because he/she hasn’t been tortured.
  • The clinician is a person in a position of authority and for that reason may not be trusted with certain aspects of the trauma history.
  • Alternatively, individuals still in custody may be too trusting in situations where the clinician cannot guarantee that there will be no reprisals for speaking about torture.
  • Torture survivors may fear that information that is 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 the context of evaluations conducted for legal purposes, the necessary attention to details and the precise questioning about history is easily perceived as a sign of doubt on the part of the examiner. Under these pressures, survivors may feel overwhelmed with memories and affect or mobilize strong defences such as withdrawal and affective flattening or numbing during evaluations.
  • If the gender of the clinician and the torturer is the same, the interview situation may be perceived as resembling the torture more than if the genders were different. On the other hand, it may be much more important to the survivor that the interviewer is a physician regardless of gender so as to ask specific medical questions about possible pregnancy, ability to conceive later, and future of sexual relations between spouses.

Counter-transference

The clinician’s emotional response to the torture survivor, known as counter-transference, also may affect the psychological evaluation. When listening to individuals speak of their torture, clinicians should expect to have emotional responses themselves. Understanding these personal reactions is crucial because they can have an impact on one’s ability to evaluate and address the physical and psychological consequences of torture. Counter-transference reactions may include:

  • Avoidance, withdrawal and defensive indifference in reaction to being exposed to disturbing material. This may lead to forgetting some details and underestimating the severity of physical or psychological consequences;
  • Disillusionment, helplessness, hopelessness and overidentification that may lead to symptoms of depression or vicarious traumatisation, such as nightmares, anxiety and fear;
  • Omnipotence and grandiosity in the form of feeling like a saviour, the great expert on trauma or the last hope for the survivor’s recovery and well-being;
  • Feelings of insecurity about professional skills when faced with the gravity of the reported history or suffering. This may manifest as lack of confidence in the ability to do justice to the survivor and unrealistic preoccupation with idealized medical norms;
  • Feelings of guilt over not sharing the torture survivor’s experience and pain or over the awareness of what has not been done on a political level may result in overly sentimental or idealized approaches to the survivor;
  • Anger and rage towards torturers and persecutors are expectable, but may undermine the ability to maintain objectivity when they are driven by unrecognised personal experiences and thus become chronic or excessive;
  • Anger or repugnance against the victim may arise as a result of feeling exposed to unaccustomed levels of anxiety. This may also arise as a result of feeling used by the victim when the clinician experiences doubt about the truth of the alleged torture history and the victim stands to benefit from an evaluation that documents the consequences of the alleged incident;
  • Significant differences between the cultural value systems of the clinician and the individual alleging torture may include belief in myths about ethnic groups, condescending attitudes and underestimation of the individual’s sophistication or capacity for insight. Conversely, clinicians who are members of the same ethnic group as a victim might form a non-verbalized alliance that can also affect the objectivity of the evaluation.

Most clinicians agree that many countertransference reactions are not merely examples of distortion but are important sources of information about the psychological state of the torture victim. The 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 are advised to examine counter-transference and obtain supervision and consultation from a colleague, if possible. Individual and group support may aslo help to prevent and/or mitigate secondary traumatisation and/or burn-out reactions that are commonly experienced by clinicians.

Working with Interpreters
Conducting Interviews
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  • Istanbul Protocol Model Medical Curriculum

    • Preface
      • Copyright and Acknowledgements
      • Resources
      • Glossary
    • Introduction
      • Curriculum Materials
      • Summary of Content
      • How to Use These Educational Resources
    • Module 1: International Legal Standards (Overview)
      • Torture
        • What is Torture
        • Purpose of Torture
        • History of Torture
        • Other Definitions
        • Cruel Inhuman & Degrading Treatment & Punishment (CID)
        • Prohibition of Torture in International Law
        • The United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 1984
        • Torture in the World Today
        • Country-Specific Legal Standards and Torture Practices
        • The Perpetrators
        • Common Situations for Torture Allegations
        • Where Does Torture and Ill-treatment Occur?
        • Obligation to Investigate and Bring Justice
        • Formal Inspection of Detention Facilities
        • Official Complaints to Human Rights Bodies and Other Organizations
        • Recently Released Detainees
        • NGO Information Gathering
        • Late Allegations
      • Prevention and Accountability
        • Prevention
        • Accountability
        • Reparation
      • International Supervisory Machinery and Complaints Procedures
        • The Human Rights Committee
        • The UN Committee against Torture
        • Regional Mechanisms
        • Other monitoring mechanisms
        • The UN Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment
        • International criminal courts and tribunals
        • The International Committee of the Red Cross (ICRC)
      • Safeguards Against Torture for Those Deprived of Their Liberty
        • Notifying people of their rights
        • Use of officially recognized places of detention and the maintenance of effective custody records
        • Avoiding incommunicado detention
        • Humane conditions of detention
        • Limits on interrogation
        • Access to a lawyer and respect for the functions of a lawyer
        • Access to a doctor
        • The right to challenge the lawfulness of detention
        • Safeguards for special categories of detainees
      • Module 1 Presentation: International Legal Standards
      • Self-Assessment and Quiz
        • Module 1 Answers
    • Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • The Istanbul Protocol
        • About the Istanbul Protocol
        • Brief History
        • International Recognition of the Istanbul Protocol
      • An Overview of the Istanbul Protocol
        • Legal Investigation of Torture
        • General Considerations for Interviews
        • Physical Evidence of Torture
        • Psychological Evidence of Torture
        • Interpretation of Findings and Referrals
        • Misuse of the Istanbul Protocol
        • Procedural Safeguards for Detainees
      • Medical Ethics
        • Introduction
        • Duties of the health professional
        • International Codes
        • Ethical rules directly prohibiting involvement in torture
        • Primary loyalty to the patient
        • Dual Obligations
        • The treatment of prisoners and detainees
        • Issues surrounding examinations of individuals in the presence of security forces
        • Abusive medical treatment
        • Consent and confidentiality
        • Security
        • Involvement of other health professionals in torture
        • Seeking further information and support
        • Country-specific legal responsibilities of health professionals for forensic documentation of torture and ill-treatment
      • General Guidelines for Gathering Evidence and Documenting Findings
        • The aims and goals of investigation
        • Multidisciplinary approach to documentation
        • Role of the health professional in the team
        • Role of the lawyer in the team
        • Role of the NGO member in the team
        • Role of judges and prosecutors
      • Documenting the allegations
        • The aim of medical documentation
        • Types of evidence
        • Medical evidence
        • Gathering of evidence
        • Essential information
        • Quality of information
        • Comparing records
      • Module 2 Presentation: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • Self-Assessment and Quiz
        • Module 2 Answers
    • Module 3: Interview Considerations
      • 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 Reactions
      • 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
      • Module 3 Presentation: Interview Considerations
      • Self-Assessment and Quiz
        • Module 3 Answers
    • Module 4: Torture Methods and their Medical Consequences
      • Introduction
      • Torture Methods
        • Beatings/Falanga
        • Ear Trauma
        • Eye Trauma
        • Restraint, Shackling and Positional Torture
        • Suspension
        • Crushing and Stretching Injuries
        • Burning
        • Electrical injuries
        • Asphyxiation
        • Violent Shaking
        • Sexual Assault
        • Sexual Humiliation
        • Prolonged Isolation and Sensory Deprivation
        • Sleep Deprivation
        • Temperature Manipulation
        • Sensory Bombardment
        • Threats of Harm
      • Psychological Consequences of Torture
        • Introduction
        • The Paradox of Psychological Consequences of Torture
        • The Psychological Consequences of Torture
        • Social, Political and Cultural Context
        • Risk factors for Trauma and Torture-Related Disorders
        • Psychological Symptoms
      • Module 4 Presentation: Torture Methods and their Medical Consequences
      • Self-Assessment and Quiz
        • Module 4 Answers
    • Module 5: Physical Evidence of Torture and Ill-Treatment
      • Physical Evidence of Torture
        • Medical history
      • The Physical Examination
        • Dermatologic Evaluation
        • Head and Neck
        • Chest and Abdomen
        • Musculoskeletal System
      • Neurological Examination
        • Head Trauma and Post-traumatic Epilepsy
        • Nerve Damage
      • Examination of Women
        • Examination Following a Recent Assault
        • Examination After the Immediate Phase
        • Follow-up
        • Genital Examination of Women
      • Genital Examination of Men
      • Perianal Examination
      • Medical Photography
        • Assessment for Referral
      • Diagnostic Tests
      • Module 5 Presentation: Physical Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 5 Answers
    • Module 6: Psychological Evidence of Torture and Ill-Treatment
      • The Central Role of the Psychological Evaluation
        • Conducting the Psychological Evaluation
        • Psychological Findings and Diagnostic Considerations
        • Components of the Psychological/Psychiatric Evaluation
      • Children and Torture
        • Introduction
        • Developmental Considerations
        • Clinical Considerations
        • Role of the Family
      • Apendix I: Sample Psychological Evaluations
        • Psychological Evaluation #1
        • Psychological Evaluation #2
      • Apendix II: ICD-10
      • Module 6 Presentation: Psychological Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 6 Answers
    • Module 7: Case Example #01
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 7 Presentation: Case Example #01
      • Self-Assessment and Quiz
        • Module 7 Answers
    • Module 8: Case Example #02
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 8 Presentation: Case Example #02
      • Self-Assessment and Quiz
        • Module 8 Answers
    • Module 9: Report Writing and Testifying in Court
      • Written Reports
        • General Considerations
        • Content of Written Reports
        • Conclusions
        • Inconsistencies
      • Providing Testimony in Court
      • Appendix: Court Testimony Guidelines and Maxims
      • Module 9 Presentation: Report Writing and Testifying in Court
      • Self-Assessment and Quiz
        • Module 9 Answers
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