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30 December 2004
To: DOJ,Command Center '
For Dan Le'Vin
Organization: Offiee ofLegaI COUDle!.
·11.8. Dena'rtm'ent of Ju.t1ce

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Number o~ pages (including cover sheet): 20 '
Comm.ents: ,<S/INF) Dan, A generic description of the
process. Thank you•.

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Background

Papa~

on- CIA's Combined Usa- of Inter~qation
'1'e~nigue_

Nota:

This pa.per

p~ovides f~ther

background infQrmatio1'1 and

<ietai1.$ on Ugh-Va1.us Detai1lee (HVD) in;tQ~og:a'tion techn:l.ques to

support t;iocument.s

on

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.the Oaparbnant of

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in1:erroqation eGlohnj,ques.

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combined. lise of

The purpose of interrogation is to parsuaae High-Value Detqinees
(HVO) to provide threat information and terrorist intelligence
in a timely manne:i, to allow thC! us Government to identify and
disrupt te~rorist plote
·~nd to oollect critioal intelligence on al-Qa'ida

In support
o{ information previously Bent to the Department of Justice,

....

I

'

this paper provides additional background on how interrogation
techniques are used, in oombination and separately, to achieve
interrogation objectives. Effective interrogation is· based on
). the ooncept of using both physical and psychological pressuxes
in a comprehensive, systematio, and cumulative manner to
influence HVO behavior, to overcome a det~ineeJs resistanoe
posture. The goal of interrogation is to create a state of
lear.n~d helplessness and Qependence conducive to the collection
of intelligenoe in a prediotable, reliaQle, and sustainable'
manner. For the purpose of this paper, the interrogation
process can be broken into thrae separate phases: Initial
Conqitionsl Transition to Interrogation; and Interrogation.

Conditions. Capture,
~. '
,
contribute to th~ physical and psychological oondition
of the HVD pr1qr to the start of interrogation. of these,
"capture shock" and detainee reactions
are
factors that may vary significantly between detainees .
A.

All

~nitial

Po~tions

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Regardless of their previous environment and .
experiences, once an HVD is turned over to. CIA a predictable set
of events occur:

. ...
~

1)

Rendition.

a.

The HVD is flown to a BlacK Site
\
A medical examination is oonducted prior to
the flight. During the flight, the detainee is
securely shackled and is deprived of sight and sound
through the use of blindfolds, earmuffs, and hoods.
There is
no interaction~with the HVO during this rendition
movement except for periodio, discreet assessments by
the ,on-board medical officer.
Upon arrival at the destination airfield, the
moved to the Black site under the same
conditions and using appropriate seourity procedures.
b.

Hve is

2) Reception at Black' Site. The HVD is sUbjected to
administrative procedures an~ medioal assessment ~pon .
arrival at the Black Site.'
1

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of

'the HVD finds himself in the complete
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the procedures he is subjected to are
precise, quiet, and almost clinical; and no one is
mistreating him. While each HVD'is different, the
rendition and reception process generally creates
significant apprehension in the HVD because of the enormity
- - ---- - - --and-suddenness. of-.the _chang.e. in environment, _the
_- .. - ._. uncertainty about what will happen next, and the potential
dread an ·HVD.might have of US cu~tody. Reception
procedures include:
a.

The HVD's head and face are shaved.

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b. A series of photographs are taken of the HVD
while nUde to document the physioal condition of the
HVD upon arrival.

c. A Medical Officer interviews the HVD and a
medical evaluation i$ conducted to assess the physical
condition. of ,th~ HVD., The medical officer aleo
determines if there are any contraindications to the
use of interrogation techniques.
d. A Psychologist interviews the HVD to assess
his mental state. The psychologist alao determines if
there are any contra indications to the use of
~nterrogation techniques.

)

Transitioning to Interrogation - The Initial Interview.
Interr'ogCj.tors use the Initial Interview to assess the initial
resistance posture of the HVD and to determine:--in a relatively
benign environment--if the HVD intends to willingly participate
with C~A interrogators. The standard on participation is set:
very high during the Initial Interview. The HVD would have to
willingly provide information on actionable threats and location
information on High-Value Targets at large--not lower level
inforrnatio~--for interrogatore to continue with the neutral
approach.

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to RQS.· Once approved, the int~rrogation process begins
the required mediqal and ppychological assessments
contain no contraindications to interrogat~on

provid~d

c.

rnt~rrogatio~.

For
descriptive purposes,' these techniques can be separated into
three catego~ias: Conditioning Techniques; Corrective
Techniqu~s; and Coercive Techniques. _ To more completely
.describe the three categories of techniques and their effects I
we begin with a summary of the deten~ion conditions that are
used in all CIAHVD facilities and that may be a factor in '
interrogations.
-!

1) Existing detention conditions. Detention
conditions are not interrogation techniques, but they have
an impact on the detainee undergoing interrogation.
Specifically, the HVP will be e:l{posed to white noise/loud
sounds (not to exoeed 79 decibels) and constant light
during portions of the interrogation process. These
conditions' provide additional operational security: white
noise/loud 60undsmask conversations of staff members and
deny the HVD any auditoryclu9s about his surroundings and
deter and disrupt the HVD's potential efforts to
comm~nicate with other detainees.
Constant light provides
an improved environment for Black Site security/medical,
p~yChoiogical, and interrogator staff to monitor the HVD.
2) Conditioning Techniques. Th~ HVD is typically
reduoedto a baseline, dependent state using the three
-- - - - - - - --inter:r:ogation techniques-·discussed below in combinatioIL-- - ---- ---- -_. -_.Establishing this baseline state is important to
demonstrate to the llVD that he has no control over basic
human needs. The baseline state also creates in the
detainee a mindset in which he learns to perceive and value
-his personal welfare, comfort, and immediate needs more
than the information he is protecting. The use of these
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conqit!oning techniques do not generally bring immediate
results; rather,' it is the cumulative effect of these
techniques,. used over time and in combination with other
interrogation techniques and intelligence exploitation
methods, which achieve interrogation objectives. These
conditioning techniques require little to no physical
interaction between the detainee and the interrogatqr. The
specific conditioning ' interrogation techniques are:

a. NUdity. The HVD's clothes are taken and he
remains nude until the interrogators provide .clothes
t'o hi-rn.
b. Sleep Deprivation. The HVD Ls placed in the
vertical ~hackling position to b~gin sleep
deprivation. Other shackling prooedures maY.be used
during interrogations. The detainee is diapered for
sanitary purposes, although the diaper is not used at
all times.
c. Dietary manipulation. The HVD is fed Ensure
Plus or other food at regular intervals. The HVD
reoeives a target of 1500 calories per day per OMS
guidelines.

l

./
3) Corrective Techniques. Techniques that re~Jire
physical interaction between the interrogator and detainee
are used principally to correct, startle, or to achieve
another enabling objective with the detainee. These
techniques-the insult alap, abdominal slaP r facial hold,
and attention grasp-are not used simultaneously but are
often used interchangeably during an individual
.
interrogation aession. these techniques generally are used
while the detainee is subjected to the conditioning
t~chniques outlined above' (nudity, sleep dePrivation, and
dietary manipulation). ,Examples of application include:

Insult Slap. The insult slap often is the
first physical technique used with an HVD once an
t e r·rogat ion .beg.ins..- As. noted, - the HV.D may ,al,r.e.ady
be nUde, in sleep deprivation, and Bubject to dietary
manipulation, even though the detainee will likely
feel little effect from these techniques early in the
interrogation. The insult slap is used sparingly but
periodically throughout the interrogation process when
the interrogator needs to immediately correct the
a.

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detainee or ~rovide a consequence to a detainee's
response or non-respons·e. The interrogator will
continually assess the effectiveness of the insult
slap and continue to employ it so long as it has the
desired effect on the·detainee. Because of the
phyeical dynamics of the various techniques, the
insult slap can be used in combination with water
dousing or kneeling stress positions. Other
combinations are possible but may not be praatical.
b. Abdominal Slap. The abdominal slap is
similar to the insult slap in application 'and desired
result. It provides tne variation necessary to keep a
high level of unpredictability in the interrogation
·pr~cess. The abdominal slap will be used sparingly
and periodically throughout the 'interrogation process
when the interrogator wants to immediately cor~eot the
detainee

.

.

'

" and the interrogator \'/111
continually assess its effectiveness. Because of the
physical dynamics of the var-ious techniques, the
abdominal alap can be used in combination with water
dousing, stress positions, and wall standing. Other
COmbinations are possib~e but may not be practical .
c. Facial Hold. The facial hold is a
corrective technique and i6 used sparingly throughout
interrogation. The facial hold is not painful and is
used to correct the detainee in a way that
demonstrates the interrooator's control over the HVD.

"

Because of the physical, dynamics of the various
techniques, the facial hold can be used in combination
with water dousing, stress positions, and wal.l
standing. Other combinations are possible but may not
be practical.
ri.• . Att.El.ntion

Grasp..

. It may be used several times in the
same iJiterrogation. This technique is usually applied

grasp the HVO and pullnim
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into. close proximity of-the interrogator (face to

face). -.Because of the -physical dyna.lYtica of the'
various techniques, the attention graap can be used in
combination with water dousing or kneeling stres8
positions. Other combinations are possible but. may
not be practical.

I-

i_

4} Coercive Techniques. Certain interrogation
techniques plaoe the detainee in more physical and
psychological stress and, therefore, are considered more
effeotive tools in persuading a resistant HVO to
participate with CIA interrogators .. These techniques-walling, water dousing, stress positions, wall standing,
and cramped confinement--are typically not used in
oombination, although some combined use is possible. For
example, an HVD in stress .poBit1on~ or wall standing oan be
water doused at the same time. Other combinations of theee
techniq~es may be used while the detainee is ~eing
subjeoted to the conditioning teohniques discussed above
(nudity, . sleep deprivation I and dietary manipulation).
Examples of coercive techniques -include:

~.

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a. Walling. Walling is one of the most
-effective interrogation techniq~es because it waars
down the HVD physically, heightens uncertainty in the
detainee abo~t what the ,interrogator may do to him,
and creates a sense of dread when the HVD knows he is
about to be walled again.

\1-cerrogator
An HVD may
be walled one time {one impact with the wall} to make
a point or twenty to thirty times consecutively when
the interrogator requires a more significant response
to a question. During an interrogation session that
is designed to be intense, an HVD will be walled
mUltiple times in the session. Because of the
--- - - _.- - " -- __ .. _ POysJ.c<;ll.. d,yrl~:i,q~ _9.~ ,Y1s)Ung t .• i ~ . .;.~ _.i.mp..rac~i9~~.._i;.q .~~~ :
it sL~ultaneously with other corxective or coercive
teohniques.

b.

Water Dousing.

The freqUenoy and duration of

water dousing applications are based on water
temperature and other safety considerati9ns as
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established by OMS guidelines. It is an effective'
interrogation'technique and may be used frequently
within those guidelines'. The physical dynamics of
water dousing are such that it can be used in
combination with other corrective and coeroive
techniques. As noted above, an HVD in stress
positions or \.;a11 standing can be water doused.
Likewise, it is possible to use the insult slap or
abdominal slap with an ·HVD during water dousing.
q.' Stress E'ositions.
The frequenoy and duration
of use' of the at'ress positions are based on the
interrogator's assessment of their continued
effectiveness during interrogation. These techniqJee
are usually self-limiting in that temporary mUscle
fatique usually leads to the HVD being unable to
maintain the stress position afte~ a period of time.
stress positions reqUiring the,HVD to be in contact
with the wall can be used in combination with water
dousing and abdominal slap. Stress positions
requiring the HVD to kneel can be used in combination
with waterdoueing, insult slap, abdominal slap;
faoial hold,' and attention grasp.

)

~

.

"

..~

d. Wall Standing. The frequenoy and,duration of
wall standing are based on the interrogator's
aaseasment of its continued effectiveness during
interrogation. Wall standing is usually self-limiting'
in that temporary muscle fat~gue usually leads to the
HVD being unable to maintaiJ:.1 the position after .a
period of time. Beoause of the physical dynamios of
·tha various techniques, wall standing' can be us~d in
combination 'with water dousing and abdominal slap.
While other combinations are possible, they may not be
practical.
e. Cramped Confinement., current OMS guidance on
the duration of cramped confinement limits confinement
in the large box to no more than 8 hours at ~ time for
. n9.,Jl\9J;.!3_,.:th?_n,J.~_hours a day, and confinement in the
small box to

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combination with other GOrrective or coercive
techniques.

D. Interrogation - A day-to-day look .. This section
provides a 'look at a prototypical interrogation with an emphasis
on the application,of ~nterrogation techniques, in co~ination
and separately .

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a. rhe HVD is brought into the interrogation
room, and under the direction of the interrogators,
stripped of his clothes, and placed into shackles .
,

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1

b. The HVD is placed standing with his back to
the walling wall. The HVD remains hooded.
c. Interrogators approach the HVD, -place the
walling collar over his head'and around his neck, and
stand in front of the HVD.

d.

The interrogators remove the HVD'B hood and
explain the HVD's situation to him, tell
him that the interrogators will do what ittakea ~o
get important information, and that he oan improve his
conditions immediately by partioipating with the
i~terroqators. The insult slap is normally used as
soon as the HVD does or says anything inconsistent
with the 'interrogators' instructions.
e.
j

,/

If appropriate, an '
insult slap or abdominal slap will follow.

.

f. The interrogators will likely use walling
once it becomes clear that the HVD is lying,
withholding information, or using other resistance
techniques.

'g. The sequence
may continue for several ~ore iterations as the
interrogators continue to measure the HVD'a resistance
posture ahd apply a negative consequence to the HVD's
resistance efrorts.

:
I

:

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h. The interrogators, assisted by security
officers (for security purposes) will place the HVD in
. ---- -- - . .- -- - - __. __ tl.'te...center.. of _.the . interr,ogation .,room. io.. the. yert.i.cJ~.J.
shackling position and diaper the HVD to begin eleep
deprivation. The HVD will be provided ,with Ensure

Plus (liquid dietary supplement) to begin dietary
manipulation. The HVD remains nude-. White noise
(not to exoeed 79db) is used in the interrogation,

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room.

The first interrogation session terminates at
this point.
1.

)

.j. This first interrogation session may last
from 30 minutes to several hours ba~ed on the
interrogators.J" assessment ot the HVD's r·esistanca
posture.

....

The three Conditioning Techniques were used to
bring the HVD to a baseline, dependent state
conductive to meeting interrogation objectives in a
timely manner .

.1

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___.__ - - - -.

3) _. SesaionT.wQ.

.a.

- - - _.. _.

The time period between Session One and.

Session two could be as brief
24 hours

as

·one hour or more than

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NO. 691

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,
In addition, the
medical and psychological personnel observing the
interrogati,ona must advise there are no
contraindtoations to another, interrogation session.

b.

c.

Like the first a6ssion, interrogators
the HVD, place the walling collar over his
head and around his neck,'and stand in front of the
HVD,
a~proach

;

".,'" ", ,)

d.

Should the HVD not respond
appropriately to the first questions, the
interrogators will respond with an insult slap or
abdominal slap to set the stage for further
questioning. ,

.'1I

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e.
L·

The interrogators
will likely use 'walling once interrogators deter.mine
the HVD is intent on maintaining his resistance
post-ure,
f. The sequence
may continue for mUltiple iterations-as the
interrogators continue to measure the avo's resistance
posture.

, g.

To increase the pressure on' the HVD(

. water. douse' the HVD for several minutes ..

/

I

h. The interrogators, assisted by security
.,~,
officers, will place the HVD back into the vertical~
ahac~ling position to res\lltle sleep deprivation.
',.
Dietary manipulation also continues, and the HVD
,.
remains nude, White noise (not to exceed 79db) is "",
used in the interrogation room. The interrogation .~
session te~inates at this point.

i.

As noted above, the duration of this session

may last from' 30 minutes to .several hours baaed on the
interrogators' assessment of the HVD's resistance
In this example of th~ seoond session, the
following techniques were used: sleep deprivation,
nudity, dietary manipulation, walling, water dousing,
attention gra.sp, insu.lt slap, and abdominal slap. The
three Conditioning Techniques were used to keep the
HVD at a'baseline, dependent state and to weaken his
posture.

. -.-_.- - --_.__._-- ~~~~~V.ie~~i:~~'~,·t;t~:·~i.6~~~~·~~i~~~~~a~;~~c{;~~
. ,t~e~e'-r ..--.----.,
Techniques were used throughout the interrogation
session based on interrogation objectives and the
interrogators' ~ssessment of the HVD'g resistance
posture.

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Session Three.
a.

, In addition, the .medical and
psychological personnel Obs6Fving the interrogations
must find no contraindications to continued
interrogation.

b. The HVD remains in sleep deprivation, dietary
manipulation and is nude.

c. Like the earlie'r sessions, the HVD begins the
session standing against the walling wall with the
walling collar around his neck.

./

d. If the HVD is still maintainin~ a resista~ae
posture, ,interrogators will continue to use walling
and water dousing. All of the Corrective Techniques,
(insult slap, abdominal ~lapr facial hold, attention.
grasp) ·may be used several times during this session·
based on the responsGs and actions of-the HVD. Stress
2ositions and ~al1 st~nding will be integrated into
interrogations

Intense questioning and walling would be repeated
multiple times.
Interrogators will often u~e one technique to support
another. .As an example, interrogators would tell
HVD in a stress position that'he (HVD) is going back
to the walling wall '(for walling) if he fails to hold
-the stress position until told otherwise by the HVD.
This places additional streS$ on the HVD who typically
-- -. - -- .-- - -----.. - ·will- ,try- to .hold the. stresiLposition illr .. as._lopg .a.s..
.._
?ossi~le to avoid the walling wall.

an

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interrogators will remind the HVD that he is
responsible for this treatment and can stop it at any
time by cooperating with the interroga~ors.
e. The interrogators, assisted by security
officers, will place the HVD back ihto the ver,tical
shackling position to resume sleep deprivation.
Dietary manipulation also continues, and the HVD
remains nude. White noi$e (not to ey.ceed 79db) is
used in the interrogation room. The interrogation
session teiminates at this point. !n this ex~ple of'
the,third session, the following techniques were used:
sleep deprivation, nudity, dietary manipulation,
walling, water dousing, attention grasp,' insult slap,
abdominal slap, stress positio~St and wall standing.
5)

Continuing Sessions.

Interrogation te~~niques assessed as being the most
effective will be emphasi'Zed while techniques will little.
assessed effectiveness will be minimized.
I
./

a.

b. The use of cramped confinement may be
introduced if interrogators assess that it .will-have
the appropriate effect on the HVD.
c. \

d. Sleep deprivation may continue to the 70 to
·120 hour range, or possibly beyond fo~ the h~rdest
resisters, but in no case exceed the leO-hour time·
limit. Sleep deprivation will end sooner. if the
medical or psychologist observer finds
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contraindications to continued sleep deprivation.

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g. The in~errogatoxs~ objective is to transition
the HVD to a point where he is participating in a
predictable, ~eliable, and sustainable manner.
.
Interrogation techniques may still be applied as
required, put become les8 frequent.
This transition pexioJ lasts
trom several days to several weeks based on the HVDs
responses and actions.

h. The entire int-errogat1on process outlined
above, including-transition, may last for thirty days
16
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On average, the actual-use of
interrogation technique!
can vary upwards to fifteen days based
on the resilience of the nYU.

-~.

If the

inter~ogation

tearnanticipates the potential need to use
interrogation techniques beyond the 30-day approval,
period,' ±t wili submit a new interrogation plan to HQS
for evaluation and approval.
2.
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.$umma·ry .
Since the start of this program, interrogation techniques
have been used in combination and separately to achieve
c~itical intelligence collection objectives.
The use of intexrogation techniques in combination is
essential to the creation of an interrogation environment
conducive to intelligence collection.' HVDs are well.
trained, of~en battle-hardened terrorist operatives, and
highly oommitted to jihad. They are intelligent and
resourceful leaders and able to resist standard
interrogation approaches .

•

•

However, there' is no template or script that states with
certainty when and how these techniques will be used in
combination during interrogation. However, the exemplar
above is a fair representation of how these techniques
are actually employed.

17
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1'10.691

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P.20

• All CIA interr6gations are ~onducted on the basis of 'the
\\ least coercive meas,:ure" principle. Interrogatoie employ
i~terrogation techniques in an escalating manne~
consistent with the HVD'~ responses and actions.
Intelliqenceproduction is more sustainable over the long
term if the actual use of interrogation techniques
diminishes steadily and the interrogation envirpnment
improves in accordance with the HVD'S demonstrated
consistent participation with the interrogators.

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, 15 Janua

2005

To: DOJ Command Center
'For Dan Levin '
Organization: Office of Legal Couns.~
, TT ~ nAnArlnum.t of Justice

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~ Dan, Latest OMS Guidelines (~ame

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changed fr~m the last version I sent you. • .

1'101'9 TO RiCfPrtN'1' '

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OMS GUIDELINES ON 1v1EDICAL AND PSYCHOLOGICAL S1.JPPORT TO
DETAINEE RE:N'DITION, INTERROGATION, ANTI DETENTION
. December 2004

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The following guidelines offer general references for medical officers suppotting
the rendition and detention of terrorists captured and turned over to the Central
Intelligence Agency for intelTogfition and debriefing. There are three different contexts
in which these guidelines may be applied: (1) during the period of rendition and initial
. g the more sus·
eriod of d briefinO'
ation site,
interrogation· 2
and (3)

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NC!.370

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NO. 378

.Guidelines for the use of sedatives.
At times it ma.y be uecessa.ry to sedAte a subject during the irJtial transfer or
ueut trans
protect either t ubject or the rendition seeuri 't

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NO. 3713

~DETENTION A1\TD INTERROGATION
General Ltttake evaluation
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P,13

Captured terrorists turned over to the C.I.A. for interrogation may be subjected to
a wide range oflegally sanctioned techniques, all of which are'also used on U.S. military
personnel in SERE training programs. These are designed to :psychologi~a11y "dislocate"
the detainee, maximize his feeling ofvulnerability and helplessness, and reduce or
eliminate his will to resist our.efforts to obtain critical intelligence.
Sanctioned interrogation teclmiques m1.lSt be specifically approved in advance by
the Director, ere in the case of each individual case. They include, in approximately
ascending degree of intensity;

)

Shaving
Stripping
Hooding
Isolation
White noise or loud music (at a decibel level 'that will nat'd~age hearing)
ContinuollS light or darkness
Uncomfortably cool environment
Dietary manipulation (sufficient to maintain
general health)
Shackling in uprigh~ sitting, or horizontal position
Sleep deprivation (up to 48 hours)

Attention grasp
Facial hold
Insult (facial) slap

Abdominal slap
Sleep deprivation (over 48 hours)
Water Dousing and tossing
Stress positions
-~on knees) body slanted forward or backward
--leaning with forehead OD'Wall
~-leaning on fingertips against wall
Walling'
Cramped confinement (Confmement boxes)
Waterboard
In all instances the general goal of these techniques is apsychological impact, and
, not some physical effe~t, with a specific goal of"dislocat[ing] his expectations regarding

a

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the treatment he believes he will recei'\·e...." The more physical techniques are .
delivered in a manner carefully limited to avoid serious physical bann. The slaps, for
example, are designed "to induce shock, surprise, and/or humiliation" and "not to inflict
physical pain that is severe or lasting:' .To this end they must be delivered in a
specifically prescnbed maliner, e.g. v,ith finger..s spread. Walling is performed only
against a springboard designed to be loud and bouncy (and cushion the blow). All
walling and most attention grasps are delivered only with the subject's head solidly
supported with a towel to avoid extensi6Jl~f1exion injury. .
OMS is responsible for assessing and monitoring the health of all Agency
detainees subject to c;enhanced>l interrogation techniques, and for determining that the
authorized administration of these techniques would not be expected to cause serious or
permanent harm. 1 I'DCI Guidelines" have been issued fonnalizing these responsibilities,
and these should be read directly.
Advance Headquarters approval is required. to use airy physical pressures;
technique-specific advanced approval is required for all "enhancedll. measures and Is
conditional aD on~site medical and psychological pers¢nne12. confitming frOm direct
detain¢e examination that the enhanced technique(s) is not expected to produce lCsevere
physical or m~ pain or suffering." As a practical matter, the detainee's physical
condition must be such that these interventions will not'have lasting effect, and his
psychological state .,.strong enough that no severe psychological harm will result.

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The medical im lications of the DCI

.

idelines are discussed below.

«

_:l The standard used by the Justice Department for "mental" hann is ''prolonged mental'
harm," Le., "mental harm ofsome lasting duratioo, e.g., mental hann lasting months or y~."
"In. the absence of prolonged mental harm, no severe ment!ll pain or suffering would have been
inflicted." Memorandum of August I, 2002, p. 15.

Unless the waterboard ia being used, the medical officer can be a physician 01' a. PA; use of the
waterboard 'requires the presence of a physician.

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P.15

Medicnl treatment

Adequate medical care shall be provided to detainees, even those undergoing
enhanced interrogation. Those requiring chronic. medications should receive them acute
medical roblems should be treateand ade ate fluids andnutrition evided.

\
The basic diet during the period of enhanced interrogation needno( be palatable,

but should include adequate fluids and nutrition. Actual consumption should be
monitored and recorded. ,Liquid Ensure (or eqnlvalent) is a good way to assure that there
is adequate nutrition. Individuals refusing adequate Ii Ods durin this sta e should :ve
fluids administered at the earliest si 9 of deh dration
If there is any question about adequacy of fluid intake,
urine output also should be monitored and recorded.

Medical officers must remain cognizant at all times of their obligation to
prevent' severe phySical or mental pain or suffering."

Uncomfortably cool environments .

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1'/0 •37B

P. 16

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Core body temperature falls after mote than 2 hours at an ambient temperature of
1QOC/:50°F, At this temperature"increased'metabolic rate cannot compensate "for heat ,
loss. The WHO recommended :minimum indoor temperature is 18°C/64°P.' The
"thennoneutral 'zone" where minimal compensatory ac,tivity is required to maintain core
temperature is 2Q"C/68°F to 30°C/86°F. Within th~ thermoneutral zone, 26°CI78°F is
considered optimally comfol1able for 11 11 clothed individuals and 30°C/86°F for naked
individuals.

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If there is any possibilitY that ,ambient temperatures are below the thennoneutr
range, they should be monitoted and the actual tern erafures documented.

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Pietary manipulation during' interrogation

During the interrogation phase, detainee diets may be modified to enhance,
compliance with interrogators and facilitate movement to the debriefing phase.. Detainees
health should not bejeQpardized by such restrictions, however, so medical officers should
attend to adequate fluid and nutrition intake. In general, daily fluid and nutritional
requ.irements may be estimated Using the following formulae:
.
Fluid requirement: 35 mIl kg I day. Will alter with ambient temperature,"body
temperature) level ofactivity, intercurrent illness. -Monitoring offiuid intake and ofurine .
output and speci.:fic gravity may be necessary when th¢ medical officer suspects the
detainee is becoming dehydrated,

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Energy requirement (male): 900 + 10x weight iJlldlograms for basal Kcal
requirement; multiply by 1.2 for sedentary activity level, 1.4 for moderate activity 1eve1.

...

. Widely available commercial weight loss programs in the US employ diets of
1000 Kca1 / day for sustained periods of weeks or longer wj:thout required medica~
supervision in persons voluntarily seeking to lose weight; these diets have proven safe
and effective in inducing short term weight loss. Franchised medically supervised .
programs may employ diets with even lower daily calorie provision (as low as 500 Kcal /
day), but do entail some risk because of alterations in serum electrolytes.
Should the interrogation team choose to limit the detainee's food intake, OMS
recommends a minimum intake of 1500 Kcalories I day, recognizing that intakes of 1,000
Kcal are safe and sustainable for weeks at a time. The nutrients may be presented as
either a babmced liquid supplement, such as Ensure Plus (360 Kcal / can), or a reduction
j n the detainee I s normal solid food iIitake. If enhance-d i.nteirogation methods are
contemplated, a liquid diet is appropriate to minimize risk to the detainee of aspiration; a .
liquid diet is mandatory ifuse of the waterboard is being con.templated.
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Water dousing .

...

Medical officers should·refer to eTC
es ora discussion of water dousing techniques, which allow for water to be
applied using either a hose connected to tap water, or a bottle or similar container as the
water source, Care must be taken to keep water away from the face to avoid risk of
accident.'t1 ingestion or aspiration.
gul e

OMS gUidelines for exposure to water are:

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1'IO.37B

P,18

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• For water temperature of41 F/ SC . to1al duration ofexposure not to e.\:ceed 20
minutes without drying and rewarming.
.
• For water temperature of 50 F /10 C • total duration of exposure not to exceed 40
minutes without dtoying and rewarming.
• Por water temperature of 59 F/ 15 C . total duration ofexposure not to exceed 60
minutes without drying and rewarming.
Th.ese standards are derived from submersion studies, and represent 2/3 of the time at
which hypothermia is likely to develop in healthy individuals submerged in water,
wearing light clothing. In our opinio~ a partial dousing; with concomitant less total
exposure and potential heat lossJ would therefore be safe to undertake within these
parameters. The total dousin time includes both the actual dousin and time· in wet

clothing.

'White noise or loud music

As a practical guide~ there is no pennanellt hearing risk for continuous, 24-hours:
a-day exposures· to sound at 82 dB or lower; at 84 dB for up to 18 hours a day; 90 dB for
up to 8 hours~ 95 dB for 4 hours) and 100 dB for 2 hoUts.Ifnecessar instruments can
be provided to measure. these ambient sound levels,

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NO.37B

P,19

Shackling and prolonged standing
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.

If the detainee is to be shackled standing with hands at or above the head (as part
of a sleep deprivation protocol), the medical assessment should include a pre..check for

Assuming no medical contre.indications are foun~ exteru:ied periods (up to 48
hours) in a standing position can be approved if the hands are no hi er than head level
and weight is bome fully b the lower extremities.

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P.28

Sleep deDrivatjon

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P.21

The maximum time frame ennicted wlder eTC POlicv for conri.:lued sleep deprivation is
180 hours,

./

NOTE: Ewminations peifarmed dU7lngperiods of-deep depr;'.'atioi1 should fnclude the
recording of current manoer of hoc Irs \Vil/lOut sleep; and, if Oi1!y a brief Test prer:eded this
period, the spec{,fics 0/ Ihe previo1iS deprivQNol1 aiso should be recorded

Cramped confinemEnt \Confinement bo:.:es)

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small box is allowable up to 2 hll1lIS. Confinementin the large box is limited to 8
consecutive hours, up to a total of 18 bours aday.
Waterboarsl
This is by far. the most tramnatic of the enJunced interrogation technlqueS. The
historiCal context here was limited knowledge ofthe use of the watorboard in SERE
training (several hundred traJoees experience. itevery year or twa). In the SERB model
the subject is immobilized an his back, and his fm:ehead and eyes c.overed with a cloth.
A stream ofwater is.directed at the upper lip. Resistantmbjects then have the cloth
lowered to cover the nose and month, as the water cantinn" to be applled;fuIly
saturating the cloth, and precluding the passage of air. Relatively little water enleIs the
mouth. The occlusion (which may be partial) lasts no more than 20 seconds. On removal
of the cloth, the subject is immediately able to breathe, but continues to bave Wllter
directed at lb. upper lip to plolong the effecL This process can C!"'tinue for several
minutes, and involve up to IS canteen cups ofwster. Ostensibly the primaIy desired
effect derivea from the sense ofsuffocation restl!ting fr.om the wet cloth temporarily
occluding the nose and mouth, and psycltological impact of the continued application of
waler after tho cloth Is removed. SERB traine.. nsually have only a single expowe to
this technique, and never more than two; SERB trsiners consider it their most effective
.techni ue, and deem it virtuaIl irresisbl>le in the trainin settin .

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T~
The SERE training pl'ogt'am has applied the waterboard technique (sirigle
exposure) to trainees for years, and reportedly there have been thousands of applications
\v.ithout significant or lasting medical complications. The procedure nonetheless carries
som.e potential risks, particularly when repeated a large number of times or when applied
to an individual less fit than a typical SERE trainee. Several medical dimensions need to
be monitored to. ensure the safety ofthe subject.

In our limited experience, ex.tensive sustained use of the waterboard can introduce
new risks. Most seriously, for reaaODS of physical fatigue or psychological resignation,
the subject may simply give up, allowing excessive filling of the airways and loss of
consciousness. An unresponsive subject should be righted inunectiately, and the
interrogator should deliver a sub~xyphoid thrust to expel the water. If this fails to restore
normal breathing, aggressive medical intervention is required. Any subject who has
reached this degree of compromise is not considered an appropriate candidate fol' the
waterboard, and the physician on the scene can not concur in further use of the
waterboard without specific C/OMS C011Sultation and approval.
A rigid guide to mediCally approved use of the waterboard in essentially healthy
indiyiduals is not possible, as safety will depend on bow the water is applied and the
. specific respoIlSe each fune it is used. The following general medical guidelines are
based on very limited knowledge, drawn from very few subjects whose experience and
r~""P0ns-e was quite varied. These represent only the medical guidelines; legal guidelines
also are operative and may be more restrictive,

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P.24

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S~eral such

sessions per 24 hours have been employed without
apparent m .ca complication. The exact"number ofsessions cannot be medically
prescnoed, and will depend on th~ re~ponse to each; however, aU medical officers must
be aware ofthe Agency policy on waterboard exposure. As ofDecember 2004, eTC
guidelines limit suoh sessions as follows:
"a. Approvals for use of the waterboard last for only 30 days. During that 3D-day period,
the waterboard may not be used on more than 5 days during that 30·day period.
'

b. The number ofwaterboard sessions during any giv~n 24-hour period may nQt exceed
two.

c. A waterboard "sessionu is the perl6d oftime in which 4subject is strapped to tho
watBrboard before being remove<!, It ms'Y involve multiple applications afwater. A waterboard
session may not last longer than tWo hours.

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d. An lIapplicationll during awaterboard session is the time peri9d in which water is
po~ed on the cloth being held on the subject's face. Under the DCI interrogation guidelinos, the
time of total contact ofwater with the face will not ex.ceed 40 aeconds. The vast majority of
applications are less than 40 seconds. many for fewer than 10 ·seconds. Indivi4ual applications
lasting 10 seconds or longer will be limited to no more than si:t applications during anyone
waterboard session. The Agency will limit the aggregate of applications to no more than 12
minUtes in anyone 24·hourperiod,"
.
"

By,days 3-5 of an aggressive program, cwnulative effects become"a potential
concern. Without any hard data'to quantify' either this risk or the .advantages ofthis
technique, we believe that beyond,this point continued intense waterboard applications
may not be medically appl'opriate, Continued aggressive use of the waterboard beyond
this point should be reviewedb the HVT team in consultation with Head arters rior to
any further aggressive use.

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P.2S

NOTE; Ir~ order to best infonnfuture medicaljudgments and recommel1dation.s. it is
important that every applictitfoll ofthE waterboard be thoroughly documenfed: how long
each application (and the entire procedure) Jasted, how milch Waier was used in the
process (realizing that much splashes ojj), how exactly the water Wa.l' applied, if a 8eal
was achieved, ifthe 1Ja.w~ or oropharynx wasfilled, what sort oflJolume was expelled,
how long was the break between applications, and haw "the subject looked between each
treatment.

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NO. 370

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P.33

General references: In addition to .standard medical works, medica1-offi.cers should refer
to the'Department ofJustice Bureau of Prisons website at www.boo.eov, accessing
"Central Office», then ('Health'Services" to view their clinical practice guidelines. These
guidelines and policies are useful references for'procedures in novel 'situations.
Other standard references which medical officers may find useful include
·"Standards for Health Selvices in Prisons u a regular publication of the National
.Commission on Correctional Health Care, last reyised in 2003. Clinical Practice tn
Correctionalll'fedicine. Michael Puisis, ed. Mosby Publishing, 1998, is a useful
cOl?pendium of care for chi'onie and infectious heaith issues in the prison setting.
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P.34

Appendix A Medical rationales for ~tations on physical pressures

Measure
Shaving

Stripping

Rationale for Limitation References

Medical
Limitation
NOlle'

Ambient'air
tomperature at
minimum 64 F118

Standard hygiene measure None
in other custodial settings;risk ofskin infections
WHO guidelines
Below this temperature
hypothermia may develop

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'Diapering

I

Evidence ofloss of Diapering commonly
skin integrity due to employed in hospital and

Hooding

contact with human. other care settings '\\o'here
waste materials
incontinence is an issue.
None;
Methodology used in
SERE training

Isolation

NOne

Methodology used ill
SERE, prison settings

White noise

79 dB max

Prevention of pennanent
hearing damage

Continuous
light or
darkness

Related to sleep
deprivation

Used in other settings

None

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Uncomfortably <3 hours be,low 60
COGI
F 116 C, 'v1th
environment
monitoring for
development of
hypothermia; use of
water v.ill further
limit exposure time'
Restricted diet Loss of 10% of

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Requires monitoring for
development of
hypothermia; risk is
patient-specific

10% loss indicates

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OSHA guidelines
for continuous '
, noise

WHO guidelines;
''Wilderness
fh
'Medi'
CIne"4 Ed OJ
Ch 6 ~ Accidental
Hypothermia; Ch 9
Immersion into
cold water
BOP guidelines'
26

NO.• 370

............. f J

body weight; or
evidence
dehydration
48 hours standard;
longer periods
require medical
monitoring

significant malnutrition
and requkes corrective
action
Shacking in
Prolonged standing lLlcely
upright sitting
to induce dependent
.or horizontal
edeina, 'increase risk for
position
DVT, cellulitis.
Water dOllsing Cessation upon
Increased h~at loss
evidence of
promoted by contact with
hypothennia;
water below 35 C; death
ambient .
can result from prolonged
temperature
(Le. 6 hour) exposure to
minimum of 64 F J 15 C water, 2 w:s at 10 C,
18 C; potable water 1 hr at 5 C; hypothemtia
source
can be induced in 3D
miIimes with' 5 C /41 F
water) 45 minutes with 10
C I 54 F water, and 60
minutes with 15 C/59 F
water immersion.
Immersion at
temperatures below 25 C I
77 F will eventually -be
fatal over time.
Sleep
Periods ofsleep
deprivation
deprivation of90+ hours
have been shmVl1 to be
gate and without long
term sequeUae in large
groups, an4 200+ hours in
individuals; required
recuperative period
undefined. Note 0.5 C
drop in body temperature,
. which may impact use of
water. Sleep deprivation
does degrade cognitive
performance, may induce
visual disturbances, may .
reduce immune
competence acutely.

P.35

of

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,

j
i

I

4;

-T~

erc guidelines;
experience with
20+ detainees

"Wilderness
Medicine" 4th Rd.,
Ch 6.- Accidental
Hypothermi~

Ch 9

Immersion into
.cold water~
Transport Canada,
"Survival ill Cold
Waters~' , PREAL

Operating .
lnstructh:ms

eTC Guidelines; .

Home, J. WhyWe
Sleep
NINDSINlH web
site

29

.... _

.............. ,1

Attention
grasp
Facial hold

Insult slap

00.370

P.36

Correct technique;
no preexisting
injury likely to be
aggravated
Correct technique;
DO preexisting
injury likely to be
aggravated
Correct technique;.
no preexisting
injury likely to be
aggra'\l-ated

Abdominal
slap

Correct technique;
no preexisting
injury likely to be
~ggravated

Stress positions Correct teqhnique;
no preexisting
injury likely to be
aggravated
Walling
Correct technique;
.no preexisting
injury likely to be

.)
Cramped

eonfinem-ent

aggravated
Con'ect technique;
no preexisting
injury likely to be
aggravated

Waterboard

resusCl

i

I

PREAL Operating
Instructions

PREAL Operating
Attention to risks of
immobilization, including Instructions
.DVT, and claustrophobia;
ensure adequate air flo\v,
ambient temperature
Risks include drowning or OMS Guidelines;
near drowningj .
hypothermia from water
exposure; aspiration
pneumonia,
laryngospasm.

0

capability

1

immediately at
hand; potable water
source
30

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P. 37

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378

P.38

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NO. 370

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P.39

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ROUTING

1m:
1
2
3
4

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'S~c hI' l..\.

DATE

INIT1ALS

IV

TrIll
O""O/A

CXSPATOi
;:u;

I\r I ElCO. N:

REMARKS;

~

CONTROL NO. __~g~.,~~~~~
COpy _---'-_ OF _~:l.:.-_

FROM; NAME. ADDRESS AND PHONE NO.

DATE

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