Mental Health Interview

Introduction, by Dr. Michael Grodin
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What you are about to see is an initial interview involving a mental health professional and survivor of torture. You may need to alter your interview techniques depending on your client's stage of recovery and on the purpose and function of the interview. The corresponding bullet points explain and supplement the material shown in the film clips. For convenience, only feminine pronouns will be used in the following text corresponding to the female patient in the film. Above all, you want to avoid re-traumatization via interrogation-like techniques and other methods that simulate your client's torture experience. You generally want to go very slowly, however the necessitation of an affidavit for an asylum hearing may call for a more formal and structured interview style. It is best to use interpreters who are culturally sensitive and medically trained.

Interview Content, by Dr. Michael Grodin and Dr. Lin Piwowarczyk

Getting Settled

• Conduct the interview in an open area so your client is not reminded of her possible past confinement.
  
• Windows, culturally appropriate artifacts, flowers, and art can help create a safe and reassuring environment. Through décor, you can personalize the interview room and communicate that you are familiar with the region of the world from which she came.
  
• Meet your client in the waiting area or at the door and direct her to a chair where the interview will take place.
• The interview should not begin until you and your client are seated comfortably at eye level.

Beginning the Interview

Introduce yourself, give your credentials, and explain your role at the treatment center in which you work. You may want to give your client a business card with your contact information.

Clarify your patient’s demographic information. How does your patient spell and pronounce her name? How would she like to be addressed? Obtain her contact information. Ask if your client had trouble getting to the office and explaining where she is. Carefully describe how long the interview session will be and what it will entail.

• Explain the principle of confidentiality to your client, as many clients may be unfamiliar with this concept. 
  

  • Assure your client that nothing will be used or reported outside of the interview room without her expressed written permission.  This includes any communication with her referring lawyer, if this was the nature of your client’s referral. 
  • If the interview is being conducted so you can prepare an affidavit for your client’s asylum hearing, it is important to explain to her that at some point an affidavit will be written, that she will have an opportunity to review it, and that it will not be sent to her lawyer without her consent.  Your client and her lawyer together will decide if the affidavit you write will be used in court. 
    
• Set some ground rules, as refugees and survivors of torture have often experienced a lack of control in their past environments. 
  
  • Give your client a sense of control, telling her that she can stop the interview at any time and refrain from answering any questions.  You may stop the interview as well if you feel things are too emotionally charged.
    
• Educate your client about your treatment center and the services it offers.

Gathering Pre-Torture Social & Work Histories

• Start the interview by focusing on your patient’s strengths and her life before the torture occurred.
  
  • Childhood and family life
  • Education and work life
    
• Has she been married and does she have children? 
• What is her experience with religion, cultural traditions, and/or political organizations?
• Clarify if other family members have also been persecuted.

Gathering Torture History

• Proceed very carefully and judiciously. 
• Phrase your questions in a way that regularizes and normalizes your client’s experiences with torture so she does not feel alienated or ashamed.
• It is often helpful to conduct your interview in a chronological fashion.
• It is important to find out where, when, and how the torture occurred for documentation purposes.  Clarify the context in which torture occurred and why she was persecuted.  Ask her to describe the circumstances of her arrest and where she was taken.
  • If your client was imprisoned, why and how did this happen? 
  • What did her cell or detention center look like?  How many people were housed in the cell?  Did she have access to water, food, a toilet, warmth, medical care, legal representation, and human rights advocacy?
  • While imprisoned, was your client able to sleep well and communicate with her family? 
  • Slowly ask her to describe what happened.  Specific areas of concern will include:
    • Was she threatened? 
    • Was your patient beaten, suspended, shaken, restrained, shackled, burned, crushed, shocked, or exposed?  Did she experience head trauma, as this may affect how well she remembers past events? 
    • Was your client forced to accuse others or to confess to things she did or did not do? 
    • Was she forced to watch or participate in mock executions or the torture of others?
    • Obtain a history of sexual violence and rape very slowly and compassionately. 
    • Note that events related to sexual trauma, as well as being forced to give information that could hurt another or one’s family, can be particularly difficult to talk about.
  • Why and how was your client released? 
  • From what did your patient derive the will to survive and the strength to endure?
  • How did these experiences immediately affect your patient? 
  • Give reassurances whenever possible.

Current Social and Work Histories

• Why and how did your client come to live near your treatment center? 
• What is your client's current living situation, including access to food, clothing, and shelter? 
• What is her level of social functioning (daily activities, occupation, social networks, recreational activities)? 

Medical, Psychological, and Trauma Histories

• Inquire about prior medical and mental health treatment and records.
  • Specific releases for these records may be needed so that you have a complete medical history when writing your client's affidavit. 
• Medical and psychological history
  • Medical problems, hospitalizations, Western and traditional medicines, allergies, diet
  • Drug history (alcohol, stimulants, depressants, tobacco) 
• Trauma history (stresses, lack of healthy family support networks, abuse, domestic violence, childhood trauma)

Assessing Mental Health Status

• Formal diagnostic tools, in certain instances may be of value, however these screening tests are generally not culturally validated.  
• Assess your client's appearance, eye contact, attitude, motor activity, affect, mood, speech, thought processes, thought content (hallucinations, delusions, judgment), insight, orientation, and cognition.  Note that cultural variations in how clients present mental disorders must be taken into account.
• Many survivors of torture are affected emotionally by their experience.  In order to create a treatment plan, assess the need for medication, and write an affidavit, it is important to evaluate the presence of psychiatric symptoms and their impact on functioning.  For example, using Western nomenclature according to the Istanbul Protocol, clients may present with major depression, post-traumatic stress disorder, somatic complaints, substance abuse, neuropsychological impairments, psychosis, bipolar disorders, enduring personality change, generalized anxiety disorder, panic disorder, acute stress disorder, somatoform disorders, and phobias.  You can find a complete DSM IV description of these disorders at . . .      

Reflection

• What is your impression of the consistency and veracity of the interview, keeping in mind that some inconsistency is expected due to the nature of torture and its physical and psychological effects on people.
• You should come to some diagnostic impression after the first interview and devise a treatment plan accordingly.

Ending the Interview

• Give timely notice before concluding the interview so your client can ask any remaining questions or talk about additional topics.
• Clarify what the next step will be, when your client's next appointment will be, and what will happen during this next meeting. 
• Inform her of your availability and the protocol she should follow if an after-hours emergency arises.
• Offer referral services if needed.
• Sign a release for your client's information.
• Hand your client a written follow-up appointment slip. 
• Walk out of the interview room with your patient.