Physical Health Interview

Introduction, by Dr. Michael Grodin
Click for the Video

What you are about to see is an interview involving a physician and survivor of torture. The purpose of this interview is to complete the process of gathering information from the patient in order to compose an affidavit. You may need to alter your interview and physical exam techniques depending on your client’s stage of recovery and on the purpose and function of the interview. The corresponding bullet points explain the material shown in the film clips and supplement it with guidance more applicable to initial meetings. For convenience, only male pronouns will be used in the following text corresponding to the male patient in the film. Above all, you want to avoid re-traumatization via interrogation-like techniques—as well as physical contact and use of routine medical instruments—that simulate your client’s torture experience. You generally want to go very slowly and preface everything you do with a thorough explanation. The necessitation of an affidavit for an asylum hearing may call for a more expedited evaluation. It is best to use interpreters who are culturally sensitive and medically trained.

Interview Content, by Dr. Sondra Crosby

Getting Settled

• Aim to make the exam room as non-threatening as possible so your patient is not reminded of his past confinement.
• Use a large room when possible. 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 he came.
• Limit the number of instruments and medical paraphernalia that are visible to the patient, as these may remind him of objects used during his torture experience.
• Refraining from wearing a white lab coat makes the encounter more personable.
• Do not bring groups of medical students into the exam room.

• Greet your patient in a culturally sensitive manner.
• You may want to do research or ask the interpreter to find out what will be appropriate for this patient.
  
• Aim to make the exam room as non-threatening as possible so your patient is not reminded of his past confinement.
  • Use a large room when possible. 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 he came.
  • Limit the number of instruments and medical paraphernalia that are visible to the patient, as these may remind him of objects used during his torture experience.
  • Refraining from wearing a white lab coat makes the encounter more personable.
  • Do not bring groups of medical students into the exam room.
  • Greet your patient in a culturally sensitive manner.
  • You may want to do research or ask the interpreter to find out what will be appropriate for this patient.

Beginning the Exam

• Introduce yourself, give your credentials, and explain your role at the treatment center in which you work.
  
• Clarify your patient’s demographic information.
  
  • How does your patient spell and pronounce his name? How would he like to be addressed?
  • Obtain his contact information.
    
• Ask how your patient got to the treatment center. Did he have trouble getting to the office? Explain to him where he is.
  
• Set the overall agenda for obtaining the necessary information for writing an affidavit. Depending upon the patient, this may take several appointments. Carefully describe how long this exam session will be and what it will entail.
  
• Inform your patient that you will be taking notes during the exams for documentation purposes. Explain what the notes will be used for and maintain eye contact throughout the exam.
  
• 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 exam room without his expressed written permission. This includes any communication with his referring lawyer, if this was the nature of your patient’s referral.
  • Explain to him that you will be writing an affidavit for his asylum hearing, that he will have an opportunity to review it, and that it will not be sent to his lawyer without his consent. Your patient and his 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 patient a sense of control, telling him that he can stop the exam at any time and refrain from answering any questions. You may stop the exam as well if you feel things are too emotionally charged. Often survivors of torture have trouble tolerating physical contact, particularly genital or rectal exams if they have experienced sexual trauma.

Pre-Torture Social and Work Histories

• Ask about his life before the torture occurred.
  • Childhood and family life
  • Education and work life
    • Has he been married and does he have children?
    • What is his experience with religion, cultural traditions, and/or political organizations?
    • Clarify if other family members have also been persecuted.

Current Social and Work History

• What is your patient’s current living situation, including access to food, clothing, and shelter?
• What is his level of social functioning (daily activities, occupation, social networks, recreational activities)?
  

Medical History

• Take a routine medical history (family history, hospitalizations, childhood diseases, allergies, medications, traditional medical practices, alcohol, stimulants, depressants, tobacco, diet, illness and pain complaints)
  - Inquire about his existing medical and mental health records.
  
• Specific releases for these records may be needed so that you have a complete medical history when writing your patient’s affidavit.
  
• Trauma history (stresses, lack of healthy family support networks, abuse, domestic violence, childhood trauma)

Gathering Torture History

• Proceed very carefully and judiciously.
  
• Phrase your questions in a way that regularizes and normalizes your patient’s experiences with torture so he 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 he was persecuted. Ask him to describe the circumstances of his arrest and where he was taken.
  • If your patient was imprisoned, why and how did this happen?
  • What did his cell or detention center look like? How many people were in his cell? Did your patient endure hard labor in detention?
  • Did he have access to water, food, a toilet, warmth, medical care, legal representation, and human rights advocacy?
  • While imprisoned, was your patient able to sleep well and communicate with his family?
  • Slowly ask him to describe what happened. Specific areas of concern will include:
    • Was he threatened?
    • Was your patient beaten, suspended, shaken, restrained, shackled, burned, crushed, shocked, or exposed? Did he experience head trauma, as this may affect how well he remembers past events?
    • Ask him to describe his acute wounds and healing process, and any medical treatment he might have received for his wounds.
    • Was your patient forced to accuse others or to confess to things he did or did not do?
    • Was he 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. You may want to wait until you have gained rapport with your patient before asking about sexual trauma.
    • 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 patient released?
      • From what did your patient derive the will to survive and the strength to endure?
      • How did these experiences immediately affect your patient?
      • Inquire about chronic sequelae of torture.
      • Give reassurances whenever possible

Physical Exam

• Be cognizant that the physical exam will be difficult for your patient and may likely cause him to feel very vulnerable. It is therefore important that you preface everything you do with a thorough explanation. Describe what the instruments are before using them. Remind your patient that he can stop the exam whenever he feels uncomfortable. Be reassuring and compassionate at all times. As you proceed, consider whether his narrative is consistent with the physical findings.
  
• Be attuned to body language.
  
• Blood pressure cuffs and otoscopes can simulate torture instruments.
  
• Conduct genital, rectal, and pelvic exams slowly and carefully, preferably deferring them until later appointments because these exams can be very traumatizing if patients have been raped. Keep in mind that many women have not seen a speculum before.
  
• Be aware that many survivors of torture have somatic complaints, meaning they have no organic origin.
  
• Document all non-torture lesions.
  
• Document all scars and deformities, especially those on the limbs.
  
• Perform careful neurological and abdominal exams, as headaches and abdominal pain are common in survivors of torture.
  
• Exam the soles of the feet, though falanga does not usually leave chronic scars.
  
• Primary care physicians should conduct mental health screenings:
  
  • Formal diagnostic tools, in certain instances may be of value, however these screening tests are generally not culturally validated.
  • Assess your patient’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 patients 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, patients 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 . . .
    • Allow the patient to get dressed in privacy and ask him to open the door when he is ready for you to return. Be prompt in returning, as waiting can trigger anxiety.

Reflection

• What is your impression of the consistency and veracity of the interview and physical findings, 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

• Leave time to ask your patient if he has any remaining questions or wants to talk about additional topics.
• Clarify what the next step will be, when your patient’s next appointment will be, and what will happen during this next meeting.
• You may want to give your patient a business card with your contact information. Inform him of your availability and the protocol he should follow if an after-hours emergency arises.
• Educate your patient about your treatment center and the services it offers.
  • The Boston Center for Refugee Health and Human Rights offers health education, treatment, and referrals to medical specialists and social support services.
    • Sign a release for your patient’s information so you may dialogue with other providers and his lawyer.
    • Walk out of the exam room with your patient.