MODULE 3 Prevention through Documentation Project

1. MODULE 3Prevention through Documentation Project INTERVIEWCONSIDERATIONS CONTRIBUTORS: Türkcan Baykal MD, Human Rights Foundation of Turkey Allen Keller MD Bellevue/NYU Program for Survivors of Torture Uwe Jacobs PhD, Survivors International Kathleen Allden, MD, Indochinese Psychiatric Clinic Vincent Iacopino, MD, PhD, Physicians for Human Rights PtD Project (IRCT, HRFT, REDRESS, PHR)

2. Module 3 Outline • Preliminary Considerations • Conducting Interviews • Interview Content PtD Project (IRCT, HRFT, REDRESS, PHR)

3. Module 3 Outline Preliminary Considerations Conducting Interviews Interview Content PtD Project (IRCT, HRFT, REDRESS, PHR)

4. Preliminary Considerations • Purpose of medical evaluations • Interview settings • Trust • Informed consent and Confidentiality • Privacy • Empathy and Objectivity • Safety and security PtD Project (IRCT, HRFT, REDRESS, PHR)

5. Preliminary Considerations Procedural Safeguards for Detainees Risk of Re-traumatisation Gender Considerations Interviewing Children Cultural and Religious Awareness Working with Interpreters Transference and Counter-Transference Reactions PtD Project (IRCT, HRFT, REDRESS, PHR)

6. Purpose of Examination • Establish facts relating to alleged incidents of torture • Document physical and psychological evidence of injuries and abuse • Correlate the degree of consistency between examination’s findings and the statements of the individual • Render expert interpretations of findings PtD Project (IRCT, HRFT, REDRESS, PHR)

7. Key role of the interview • Effective and appropriate and interviewing skills essential to medical evaluations • Interviews provide foundation for accuracy in medical reports in legal settings PtD Project (IRCT, HRFT, REDRESS, PHR)

8. Tasks of the Interview • Information gathering • Emotion handling • Providing Information PtD Project (IRCT, HRFT, REDRESS, PHR)

9. Application of Preliminary Interview Considerations • Recounting events of abuse is extremely stressful and potentially retraumatising for the victim. • Listening to accounts of torture/trauma can be very stressful for the interviewer (Vicarious traumatisation) • Establishing rapport and eliciting thorough history takes time PtD Project (IRCT, HRFT, REDRESS, PHR)

10. Application of Preliminary Interview Considerations (continued) • There is variability in degree of physical and psychological signs, symptoms or consequences which a torture victim will manifest • There is variability in the manner in which torture victims conduct themselves in interviews and in recounting the events of their abuse • There is variability in the amount and detail of information which an individual will recall with regards to the events of the trauma PtD Project (IRCT, HRFT, REDRESS, PHR)

11. Interview Settings • Safe, comfortable settings • Room with appropriate physical conditions • Access to toilet facilities and refreshment opportunities- water and tissues within reach • 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 • Clinician should choose setting PtD Project (IRCT, HRFT, REDRESS, PHR)

12. Trust • Essential component of eliciting an accurate account of abuse. • Requires: • Active listening • Meticilous communication • Courtesy • Genuine empathy • Honesty • Safe & comfortable setting • Establish interviewee’s control over process (stopping, taking breaks) PtD Project (IRCT, HRFT, REDRESS, PHR)

13. Informed Consent • 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 • Understands information provided • Gives consent voluntarily • Provides authorisation for consent PtD Project (IRCT, HRFT, REDRESS, PHR)

14. Informed Consent • Explain the purpose of the meeting • Explain the independent but non-adversarial role • Explain who you are • Clarify the length and structure of interview (including time limitations) • Confidentiality issues • Right to refuse PtD Project (IRCT, HRFT, REDRESS, PHR)

15. Informed Consent Required elements: Introduction of clinician and role (independent, non-adversarial) Purpose of evaluation Length and structure of interview (including time limitations) Confidentiality issues (such as limitations) Explanation of right to refuse PtD Project (IRCT, HRFT, REDRESS, PHR)

16. Confidentiality • Clinicians have a duty to maintain confidentiality of information and to disclose information only with the patient’s informed consent • The patient should be clearly informed of any limits to the confidentiality of the evaluation and of any legal obligations for disclosure of the information. PtD Project (IRCT, HRFT, REDRESS, PHR)

17. Privacy • Degree of confidentiality and security determines whether questions can be asked safely • Police or other law enforcement should never be present in examination room • Police presence should be noted in the medical report and may be grounds for disregarding a “negative” report PtD Project (IRCT, HRFT, REDRESS, PHR)

18. Empathy and Objectivity • Medico-legal evaluations should be conducted with objectivity and impartiality • Objectivity not in contradiction with being empathic • maintain professional boundaries. • same time acknowledge pain and distress when observed PtD Project (IRCT, HRFT, REDRESS, PHR)

19. Safety and Security • Consider the possibility of reprisals • Do not promise a level of security that cannon be achieved • Do not conduct an evaluation if reprisal is certain • Safeguard identifying information • Evidence of torture/ill treatment should result in a transfer of custody to judicial authorities PtD Project (IRCT, HRFT, REDRESS, PHR)

20. Procedural Safeguards Forensic medical evaluation of detainees requires official written request and services should be independent from police/prison system and free of charge Detainees, their lawyers or relatives: right to request medical evaluation to seek evidence of torture or CID Right to obtain second/alternative medical evaluation by qualified physician even if previously examined Mandatory that detainees undergo a preliminary medical examination at the time of detention; repeat evaluation upon release PtD Project (IRCT, HRFT, REDRESS, PHR)

21. Procedural Safeguards The detainee should: be taken to exam by officials not working in his/her detention site be examined by qualified doctor be examined without police officer present If police, soldier, warden, or other law enforcement officers present: Should be noted by physician in report May be grounds for disregarding “negative” medical report If medico-legal evaluation, should use a standardized medical report form which includes: allegations of abuse details of injuries psychological findings explanations of patient opinion of doctor PtD Project (IRCT, HRFT, REDRESS, PHR)

22. Procedural Safeguards Medical report: should never be transferred/copied for law enforcement should be transmitted to official requesting report If exam supports allegations of torture or ill-treatment, detainee: should not be returned to detention site should be presented to competent prosecutor or judge Access to the lawyer should be provided at the time of the medical examination. PtD Project (IRCT, HRFT, REDRESS, PHR)

23. Risk of re-traumatisation • Structure interview to minimize risk of re-traumatizing torture survivor • Balance two important requirements: • need to obtain detailed, accurate account • importance of respecting needs of person being interviewed PtD Project (IRCT, HRFT, REDRESS, PHR)

24. Risk of re-traumatisation Avoid any manner, approach, style whichmay remind survivor of torture situation; • Avoid authoritative instructions and questions • Do not make the patient wait • Give the patient control • Give time, space for his/her own questions/needs • Provide comfortable setting, adequate time PtD Project (IRCT, HRFT, REDRESS, PHR)

25. Gender Considerations • Same-sex interviewing preferable: respect individual choices, if possible • Sexual abuse common among torture survivors • Influences examination • Male survivors may be more reluctant to disclose sexual abuse • Consider cultural and individual factors in determining appropriate interviewing strategy PtD Project (IRCT, HRFT, REDRESS, PHR)

26. Interviewing Children • Involve parent or guardian • Required for consent • Required presence for detailed history/exam in • Where possible, the family should be treated together • Child’s injuries should be documented and managed by paediatric specialists • Ensure safety and comfort • Short attention spans may require frequent breaks PtD Project (IRCT, HRFT, REDRESS, PHR)

27. Cultural and Religious Awareness • Clinicians should be aware of beliefs and cultural norms • Interpreters may facilitate understanding • Interviewers should make sure to conduct him or herself in a manner that does not offend cultural or religious sensibilities PtD Project (IRCT, HRFT, REDRESS, PHR)

28. Working with Interpreters • Interpreters have similar professional obligations to the examiner • Interpreter should not be • Law enforcement • Government employee • Friends or relatives (as they may not be impartial, can be important witnesses) • Examiner should maintain contact and talk to examinee, not interpreter PtD Project (IRCT, HRFT, REDRESS, PHR)

29. Transference & Counter-transference • Clinicians should be aware of potential emotional reactions that evaluations of severe trauma may elicit in interviewee and interviewer • These emotional reactions are known as transference and counter-transference. PtD Project (IRCT, HRFT, REDRESS, PHR)

30. 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 PtD Project (IRCT, HRFT, REDRESS, PHR)

31. Transference • Evaluator’s questions may be experienced as: • forced exposure akin to an interrogation • sign of mistrust or doubt on the part of the examiner • interview situation may be perceived as ressembling torture situation • The evaluator may be perceived as • having voyeuristic and sadistic motivations • a person with authority (in a positive or negative sense) • being on the side of the enemy PtD Project (IRCT, HRFT, REDRESS, PHR)

32. Transference • For all these and other similar perceptions, the subject may experience: • distress • fear • mistrust • forced submission • anger, rage • shame • worry or suspicion • or may be too trusting and expectant PtD Project (IRCT, HRFT, REDRESS, PHR)

33. Counter-transference • The clician’s should also be aware of his/her own potential personal reactions, feelings and how that might influence the interviewer’s perceptions and judgments PtD Project (IRCT, HRFT, REDRESS, PHR)

34. Counter-transference • Common counter-transference reactions include: • Avoidance, withdrawal, defensive indifference • Disillusionment, helplessness, hopelessness and over-identification • Omnipotence and grandiosity in the form of feeling like a savior, the great expert on trauma or the last hope of the survivor • Feelings of insecurity, feelings of guilt, excessive rage toward torturers and persecutors or toward the individual PtD Project (IRCT, HRFT, REDRESS, PHR)

35. Transference/Counter-transference • Important sources of information about the psychological state of torture survivor • 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 should evaluate counter-transference and obtain supervision and consultation from a colleague • Individual and group support may help to prevent and/or mitigate secondary traumatisation PtD Project (IRCT, HRFT, REDRESS, PHR)

36. Possible Effects of Counter-transference Reactions • Underestimating severity of consequences of torture • Forgetting details • Leading to disbelief regarding veracity of alleged torture • Failure to establish necessary empathic approach • Over-identification with survivor • Vicarious traumatisation, burn-out • Difficulty in maintaining objectivity PtD Project (IRCT, HRFT, REDRESS, PHR)

37. Module 3 Outline Preliminary Considerations Conducting Interviews Interview Content PtD Project (IRCT, HRFT, REDRESS, PHR)

38. Conducting Interviews • Types of Questions • Cognitive Techniques • Summarising and Clarifying • Difficulty Recalling and Recounting • Assessing Inconsistencies PtD Project (IRCT, HRFT, REDRESS, PHR)

39. Types of Questions • Utilize open ended questions • “Can you tell me what happened?” • “Tell me more about that.” • Based on information elicited, more specific details should be sought PtD Project (IRCT, HRFT, REDRESS, PHR)

40. Techniques of Questioning • Listening is more important than asking questions • Leading questions may be good or bad • Consider using checklists PtD Project (IRCT, HRFT, REDRESS, PHR)

41. Cognitive Techniques • Free narrative in interviewee’s own words • Followed by direct question for clarification • Clarification of chronological order of events • Descriptions from another point of view (eg. an observer) PtD Project (IRCT, HRFT, REDRESS, PHR)

42. Summarizing and Clarifying • Improve accuracy of information by: • Clarifying details • Summarise key points periodically • Consider follow-up interview to address outstanding questions or any inconsistencies PtD Project (IRCT, HRFT, REDRESS, PHR)

43. Difficulties in Recalling and Recounting Factors directly related to the torture experience Factors related to the psychological impact of torture Cultural factors Factors related with the interview conditons or communication barriers PtD Project (IRCT, HRFT, REDRESS, PHR)

44. Difficulties in Recalling and Recounting • Factors directly related to the torture experience • Torture itself such as blindfolding, drugging, lapses of consciousness, etc. • Disorientation in time and place during • torture • Neuro-psychiatric memory impairment from head injuries, suffocation, near drowning, starvation, hunger strikes or vitamin deficiencies • Experiencing repeated and similar events may have led to difficulties recalling details of specific events PtD Project (IRCT, HRFT, REDRESS, PHR)

45. Difficulties in Recalling and Recounting • Factors related to the psychological impact of torture • Memory disturbances related to PTSD or Depression • Coping mechanisms such as denial and avoidance • Other psychological symptoms such as concentration difficulties, fragmentation or repression of traumatic memories, confusion, dissociation, amnesia • Feelings of guilt or shame PtD Project (IRCT, HRFT, REDRESS, PHR)

46. Difficulties in Recalling and Recounting • Factors related to cultural norms • Cultural differences in the perception of time • Culturally prescribed sanctions that allow traumatic experiences to be revealed only in highly confidential settings. PtD Project (IRCT, HRFT, REDRESS, PHR)

47. Difficulties in Recalling and Recounting • Factors related to the interview conditons or communication barriers • Fear of placing oneself or others at risk • Lack of trust • Lack of feeling safe • Environmental barriers such as lack of privacy, inadequate time • Physical barriers such as pain or other discomforts • Socio-cultural barriers such as the gender of the interviewer, language and cultural differences • Transference/counter-transference reactions • Misconducted and/or badlystructured interviews PtD Project (IRCT, HRFT, REDRESS, PHR)

48. Assessing Inconsistencies Problems recalling and recounting information commonly manifest as inconsistencies in an individual’s testimony. Be aware that inconsistencies do not mean that allegations of torture are false. ! PtD Project (IRCT, HRFT, REDRESS, PHR)

49. Assessing Inconsistencies • If possible, the investigator should ask for further clarification • When this is not possible; The investigator should look for other evidence. A network of consistent supporting details can collaborate and clarify the person’s story. PtD Project (IRCT, HRFT, REDRESS, PHR)

50. Assessing Inconsistencies If the clinician suspects fabrication; • The clinician should try to identify potential reasons for exaggeration or fabrication • Also, should keep in mind that such fabrication requires detailed knowledge about trauma-related symptoms and findings that individuals rarely possess PtD Project (IRCT, HRFT, REDRESS, PHR)