Medico‐legal History Taking
ELLEN JOHNSON BA , RN, SANE‐A , CEN
Ellen Johnson RN, SANE‐A
Objectives
Demonstrate an understanding of the key components of medico‐legal history taking associated with an
adult/adolescent sexual assault Identify techniques for establishing rapport and facilitating disclosure
Ellen Johnson RN, SANE‐A
Objectives
Discuss the importance of incorporating trauma informed practices into history taking with the sexual assault patient Select appropriate nursing diagnosis and set priorities for your patient
Ellen Johnson RN, SANE‐A
Goals of the medico‐legal history
Get as accurate an accounting of what happened as pt. is able to give
Determine likely location of injury Decide where to collect evidence with information obtained during the history Provide psychosocial support throughout
Ellen Johnson RN, SANE‐A
Where do I start?
Check in with the nursing personnel who initially cared for the patient
◦Get brief report from nurse
◦Ask if there is anything else you need to know If the police are present, ask them to share what they know
Ellen Johnson RN, SANE‐A
Begin the healing
Rape is an act of violence
◦Robs victim of sense of security
Guilt/fear are felt long after patient leaves the ER How the patient is treated initially has overwhelming impacts to their psychological well being
◦Gentle, compassionate medical care can help with recovery
◦It is one of the reasons our role is so vital to ongoing health
Victim reactions
There is no one way, or no “right” way for the victim to react to the sexual assault
Accept them for how they are right now
Ellen Johnson RN, SANE‐A
Set the stage
A private environment is mandatory
Calm, gentle, non‐judgmental communication
◦“I am so sorry this was done to you”
Begin by introducing yourself and your role Clarify the name the pt. prefers to be called
◦Also clarify pronouns/gender Talk briefly about next steps
Ellen Johnson RN, SANE‐A
Give the patient choices
Choices and control were removed with the assault
Give the ability to make choices and regain control back to the patient
◦Whether to make a police report
◦Whether to have an evidentiary exam
◦Whether to stop the exam at any point if they wish
Ellen Johnson RN, SANE‐A
Connect with your patient
“What are you most concerned about today?”
Consider age, developmental level, gender, language and cultural differences as you establish rapport
Ellen Johnson RN, SANE‐A
Obtain consent
ER nurse has obtained verbal consent for exam SANE obtains written consent for exam
If you have doubts if patient can sign consent clarify
◦Ask if pt. normally signs for medical care
◦What if pt. is intoxicated?
Ellen Johnson RN, SANE‐A
Obtain consent
If pt. is developmentally delayed or has dementia you may need consent of guardian (determine what guardian has control over)
Ask group home staff or nursing home if pt. signs for self If guardian will not consent and exam needs to be done may need to get a court order
◦Law Enforcement can help with this
◦LE can NOT give consent for the exam
Consent
Explain the consent form to patient
◦Authorization to examine and treat for injury sustained during sexual assault
◦Authorizes tests for legal evidence, photography
◦Release of information to law enforcement agencies
◦Allows for information to be used for educational purposes
◦Waives medical privilege, authorizes SANE to testify and speak to LE, attorneys, crime lab
◦Medical exam is NOT to treat pre‐existing conditions
Cross off parts of the consent that pt. does not agree to
Ellen Johnson RN, SANE‐A
Who is present
NOT the family, friends, clergy, etc.
◦May be more difficult to fully disclose events with visitors present
Advocate, interpreter may be present
Patient may decline to have anyone else present during interview
May have staff in training present if patient allows
Ellen Johnson RN, SANE‐A
To begin taking a history…
Explain the process, and reason for questions which may seem strange Explain the presence of the computer
Tell pt. you may have them pause so you can get the events accurately documented (interrupt as little as possible)
Let them know how important it is to accurately document the details of the assault
Understanding what happened will help you determine where to collect swabs and look for injuries and assess emotional trauma
Ellen Johnson RN, SANE‐A
Goals
Obtain a baseline health history
Obtain as accurate, and complete a history of the assault as pt. is able to give
Determine if pt. requires further evaluation for emotional crisis or physical injuries
Ellen Johnson RN, SANE‐A
Baseline health history
Allergies
Current medications Recreational drug use
Chronic illnesses/medical conditions Past surgeries
Ellen Johnson RN, SANE‐A
Ano‐genital history
Last consensual intercourse Pregnancy history
Contraceptive usage LMP
Observations
Observe the patient’s emotional status and general appearance
Note patient’s level of consciousness and ability to express themselves
Ellen Johnson RN, SANE‐A
Take your time, do not rush
Ellen Johnson RN, SANE‐A
Secondary victimization
Victims may view attitudes and beliefs of professionals they encounter as blaming and insensitive‐ explain reason for questions
◦Worsens the trauma
◦Viewed as re‐victimizing
◦Reluctant to continue to seek help
Ellen Johnson RN, SANE‐A
SA victims have confusing behaviors
May not report until hours/days after assault May not fight back or yell
May not remember details of the assault
May continue to have a relationship with assailant These behaviors can lessen credibility
◦Can lead to skepticism
◦May be perceived to be lying
Ellen Johnson RN, SANE‐A
Sexual assault victim behavior
There are neurobiological reasons for much of this behavior
Ellen Johnson RN, SANE‐A
Neurobiology of sexual assault
Brief overview of brain structures (related to memory)
Brain responses during sexual assault Implications of trauma and memory for criminal justice system
Interviewing tips and ideas
Why is this important?
Understand how a victim’s brain processes information during an assault
Identify the effects trauma has on memory and a victim’s ability to recall details of an assault
Identify reasons for varying behaviors and emotions in victims following assault
Ellen Johnson RN, SANE‐A
Contributors to Research, Information, Techniques, & Ideas
Rebecca Campbell, PhD
◦Neurobiology of Trauma
◦PhD in Community Psychology
◦Current work focuses on SANE programs and the criminal justice system
◦Funded by National Institute of Justice
◦Published over 75 scientific papers and 2 books
◦Conducted over 150 presentations
◦State, national, & international conferences
Ellen Johnson RN, SANE‐A
Subject experts
Russell Strand
◦International expert in:
◦Child abuse and sexual assault investigations
◦Domestic violence intervention
◦Human trafficking
◦Critical incident peer support
◦Creator of the Forensic Experiential Trauma (FETI) Interview Retired U.S. Army CID Special Agent
Ellen Johnson RN, SANE‐A
Subject experts
Clinical Psychologist, whose research focuses on causes and consequences of interpersonal violence
Works with organizations that focus on men who have suffered sexual abuse
David Lisak, PhD Forensic Consultant The Undetected Rapist
Ellen Johnson RN, SANE‐A
Trauma and memory
Victims of sexual assault and other trauma may have difficulty
remembering details of what happened This can be very frustrating for them and the professionals trying to help them
Ellen Johnson RN, SANE‐A
Prefrontal cortex
Pre‐Frontal Cortex
• Abstract thinking
• Problem solving
• “Voice of reason”
• Not fully developed until mid 20’s
Prefrontal cortex
Turns off during high stress/traumatic situations due to release of stress hormones
We are unable to:
◦remember our values
◦think logically
Ellen Johnson RN, SANE‐A
The limbic system
Detects a threat (rape) and stress hormones are released
Deals with processing emotions and long‐term memory
Processing info into memories is impaired due to stress
hormones
Pre‐Frontal Cortex
Ellen Johnson RN, SANE‐A
Brain responses during trauma
AKA fear
Hormones released
Rational thought process impaired May have flat affect
May have decreased energy
Higher brain functions may shutdown from hormone overload
Ellen Johnson RN, SANE‐A
Neurobiological changes
Stress hormone release leads to a wide range of emotions and behaviors
◦Flat affect
◦Strange emotions
◦Mood swings
◦Often misinterpreted as being
“cavalier” and lying
Ellen Johnson RN, SANE‐A
Victim narratives will fluctuate
Every time a victim recounts the incident, the details will be slightly different depending on which pieces are recalled
Responses of the brain & body during trauma
Freeze Fight Flight
Ellen Johnson RN, SANE‐A
Dissociation
• Defense mechanism (of the brain) to protect an individual against overwhelming sensations & emotions
◦ “What was happening seemed unreal to me – like I was in a dream or watching a movie or a play”
◦ Felt “disconnected” from my body
Ellen Johnson RN, SANE‐A
Tonic immobility
Mentally know what’s happening but physically unable to move (like being awake during surgery)
Ellen Johnson RN, SANE‐A
Tonic immobility
Uncontrollable response
◦Normal in extremely fearful situations
◦Many feel guilty that they did not “fight back”
◦More common with prior history of sexual assault
Ellen Johnson RN, SANE‐A
Tonic immobility
Caused by:
◦Fear
◦Physical restriction
◦“Perceived” inability to escape
Ellen Johnson RN, SANE‐A
Memory fragmentation
Memory recall can be very slow and difficult
◦Memories are “fragmented” – they come only in bits and pieces (often do not follow a timeline)
◦Process can be very frustrating for victims and professionals
What happens as a result?
Fragmented memory (related to trauma) often misinterpreted as lying
According to Campbell’s research…….
◦Law enforcement believes that 50%+ reports are false (depending on jurisdiction)
◦Research and peer‐reviewed, published literature cites between 2‐8%
Ellen Johnson RN, SANE‐A
How do we get the memories out?
Give them time Be patient and understanding They need time to think and process
Ellen Johnson RN, SANE‐A
Effects of alcohol on memory
High Blood Alcohol
◦ Both “context”
details and
“sensory”
details will be impaired
Ellen Johnson RN, SANE‐A
Low blood alcohol
◦Impairs “context” details
◦Time, place, physical scene, collecting details in a “particular sequence”
◦5 senses still able to gather, store, and recall information (especially smell)
Ellen Johnson RN, SANE‐A
Victim reassurance
It is important the victim knows these are normal reactions to trauma
More details may surface over time It may be beneficial to be interviewed by LE days after the assault (if possible)
◦SANE history will be done at time of exam
Ellen Johnson RN, SANE‐A
What can we do?
Use a Trauma‐Informed Process Improve Interview Techniques….
Establish trust
Be gentle
Provide choices where possible to give back control Explain next steps
Ellen Johnson RN, SANE‐A
Set up the interview conditions
Find a safe, comfortable, private location
Offer comforts‐ beverage (after SANE exam/oral swabs), tissue, breaks
Acknowledge how difficult this is
Ellen Johnson RN, SANE‐A
Advocates can help throughout
Provide emotional support
◦Medical exam
◦LE interview
◦Prosecution interview
◦Court
◦Can help with protection orders
◦Extended follow‐up and support as needed
Ellen Johnson RN, SANE‐A
Compassion and empathy are key
Patient needs to be able to trust us Being a warm, open, empathic provider does not make us any less neutral
◦However, it will help us get better and more complete info
Ellen Johnson RN, SANE‐A
Be cautious when using words such as rape, victim, sexual assault, assault
They may not associate those words with their experience yet
Hearing those words may trigger a stress response and reactivate the trauma
Ellen Johnson RN, SANE‐A
Interview Suggestions
Interrupt as little as possible
You can go back and fix the typing later if this is a computerized record (harder to do with paper)
Try to form a connection with the victim
◦Compassion, respect
◦To increase their comfort level
◦To get as much info as possible
Develop a pattern with how you collect a history and try to stick with it, however, take pt. needs into consideration
Who, what, when, where, why, how
Most criminal justice professionals are trained to obtain this type of information
Ellen Johnson RN, SANE‐A
Trauma informed interviewing
◦A way to unlock a victim’s experience while taking into account the associated trauma
Ellen Johnson RN, SANE‐A
Info is not easily recalled
When a victim experiences trauma the
prefrontal cortex may shut down and leave the more primitive limbic system to experience and record the event
Brain is very good at recording experiential and sensory info, but not so good at recalling the who, what, when, where, why and how
Ellen Johnson RN, SANE‐A
To begin
Explain that you will ask questions that may sound odd, but the questions are intended to help with recall of the assault and the patient’s experience Start with one basic, open‐ended question
◦What are you able to tell me about your experience?
(in your own words)
◦Just let them talk (ask clarifying questions later)
Ellen Johnson RN, SANE‐A
Avoid “why” questions
Interpreted as blaming
Victims are easily re‐traumatized by healthcare personnel, LE,
prosecution, and loved ones
Ellen Johnson RN, SANE‐A
Continue
Engage the pt. in recalling memories from the event based on their personal
experience and their senses
◦What was your thought process during this experience?
◦What are you ableto remember about…what you saw, heard, touched, tasted, heard?
Explain why you are asking these questions
When we experience trauma parts of our brain
“shut down”
Memories are attached to our 5 senses and may be recalled when we think about these senses
Some of these questions may not have an answer.
That is OK!
Ellen Johnson RN, SANE‐A
Tell me more about…
Ellen Johnson RN, SANE‐A
Ask about your patient’s reactions
What were your reactions to this experience?
◦Physically…
◦Emotionally…
◦Ask them to describe and recall as many memories as possible
◦Give them time
◦Try to avoid follow‐up questions at this point
Ellen Johnson RN, SANE‐A
More about their experience
What was the most difficult part of this experience for you?
What, if anything, can’t you forget about this experience?
Ellen Johnson RN, SANE‐A
Finally
Clarify any unclear information
This step is completed only after facilitating all you can about the pt.'s “experience”
◦“Can you tell me more about….”
◦Ask questions to help you know where to collect specimens
Ellen Johnson RN, SANE‐A
What if this is not working well?
DFSA victims may not have memories
May need to switch gears and ask pt. to relay what they recall, acknowledging this may be limited
Some pts may be triggered by experiential
questions and may need to be asked these later in the exam process‐ take your cue from your pt.
Why ask these questions?
◦We want to know about the patient’s experience so we can address their trauma
◦Warn pt. about future triggers
Ellen Johnson RN, SANE‐A
Additional info/event history
Where do you have pain?
Do you have any injuries which caused you to bleed?
Did the assailant do or say anything to make you afraid? (threats, coercion, force, intimidation, assailant size relative to pt.
size)
Ellen Johnson RN, SANE‐A
Additional info/event history
Did you scratch the assailant?
Did the assailant bleed?
Were there any objects used in the assault?
Was anyone else present when you were assaulted?
The questions you ask will help you determine where to collect samples and guide your exam
Ellen Johnson RN, SANE‐A
Additional info/event history
Actual/attempted acts
Use of weapons/restraints/threats Use of recording device (photos/video) Known drug/alcohol intake
◦Did the pt. feel as expected after voluntary ingestion?
◦Do you suspect DFSA?
Strangulation?
Acts which could destroy evidence
Ellen Johnson RN, SANE‐A
At the end of the history
Let the patient know what to expect next Encourage questions
Validate how difficult this was and provide support
Ellen Johnson RN, SANE‐A
Does patient wish to report to LE?
If police report has not already been made, discuss reporting options
◦This discussion takes place whenever it “feels right”
and may be introduced at several points in the interview/exam process
◦Emphasize choice
◦May choose to make evidence restricted or unrestricted
Medical and LE interviews are separate
Medical providers need different info Less problematic getting medical provider testimony admitted in court
Know why you are asking the questions
◦Be careful not to stray into investigator territory
Ellen Johnson RN, SANE‐A
Find out more…
Trauma informed approach to interviewing is VERY important
Listen to webinars on this topic Key words
◦Neurobiology of trauma/sexual assault
◦Trauma informed care
◦Forensic Experiential Trauma Interview
Ellen Johnson RN, SANE‐A
References
http://nij.gov/multimedia/presenter/presenter‐
campbell/
http://www.army.mil/article/72055/Army_expert_r eceives_national_recognition_for_combating_sexu al_assault/
https://nij.gov/multimedia/presenter/presenter‐
campbell/Pages/welcome.aspx
Ellen Johnson RN, SANE‐A
