Istanbul Protocol Model Medical Curriculum

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.

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 … Continue reading →