Bonus: Unabridged Conversation with Dr. Marc Feldman

True Story Media.

Hello, it's Andrea Dunlop, host and creator of Nobody Should Believe Me.

I am coming to you today with another bonus episode that we are releasing from the Patreon.

This is my complete conversation with Dr.

Mark Feldman, who is a clinical professor of psychiatry and psychology at the University of Alabama.

He is one of of the best known munch housing biproxy experts in the world, and he is also a good friend.

You heard from Mark in a couple of episodes in season one.

This is my conversation with him in its entirety, and I think it includes lots of interesting tidbits that did not make it into the episodes.

So if you are interested in more content like this, we have lots of it over at our Patreon.

And if monetary support is not an option for you at the moment, if you would like to support the show, it is always very, very helpful to us if you rate, review, and share the show wherever you talk about podcasts.

We are hard at work on season two right now.

Really excited to bring that to you guys in early spring.

This is going to be a completely different kind of story than the first case that we covered in season one.

It's another Mike Weber case.

So there'll be some familiar voices in season two.

There'll be some new voices, some new angles.

And this was not something I was completely expecting when we set out to make it, but there's going to be more about my story as well.

So thank you so much for listening, and I hope you enjoy my conversation with Mark.

If you just can't get enough of me in your ears, first of all, thank you.

I have a job because of you.

And secondly, did you know that I have a new audiobook out this year?

The Mother Next Door, which I co-authored with Detective Mike Weber, is available in all formats wherever books are sold.

It's a deep dive into three of Mike's most impactful Munchausen by proxy cases, and I think you'll love it.

Here's a sample.

When Susan logged in, what she discovered shocked her to the marrow of her bones.

Though the recent insurance records contained pages and pages of information about Sophia, there was nothing about Hope.

Susan dug deeper and looked back through years of records.

There wasn't a single entry about Hope's cancer treatment.

For eight years, the Butcher family had lived with a devastating fear that their beloved daughter and sister was battling terminal cancer.

For months, they'd been preparing for her death.

But in that moment, a new horror was dawning.

For nearly a decade, hope had been lying.

The conjuring last rites.

On September 5th.

The Conjuring Last Rites Only in Theater September 5th.

Richard R.

Yeah, my name is Mark

M-A-R-C Feldman, F-E-L-D-M-A-N,

M-D,

and I'm clinical professor of psychiatry at the University of Alabama and the author of the book, Dying to Be Ill.

Well, I got interested in Munchausen by proxy about 30 years ago when I was doing research for my first book on factitious disorder.

I had never heard of Munchausen by proxy or medical child abuse, but as I did research on the adult variation where people harm themselves for attention, I came across that topic and became fascinated and read all I could about it.

And then when my book appeared, I started getting phone calls requesting consultation in Munchausen by proxy cases.

And I basically haven't looked back.

And how long has it been now?

My first

encounter with a factitious disorder or Munchausen patient was in about 1989.

And the book came out in 1993.

So it was during that time I did my research into Munchausen by proxy and

have been fascinated by it ever since.

I wanted to talk a little bit actually about how you and I first met.

My

recollection is that I was interviewed by a New York City writer.

And she had encountered a case of Munchausen syndrome, someone who faked cancer.

And she told me about some of her colleagues and friends who were intrigued with the topic for various reasons.

And one of those people was you.

And I looked forward to the time we could talk.

That happened.

I think we talked for an hour and a half, the first time we spoke at all.

And we've been good friends and colleagues ever since.

Yeah.

And, you know, that

first

conversation for me was really so revelatory.

And it was really my first chance to ever talk to someone who I didn't have to explain everything to.

And that was a huge relief for me.

It's also a bit isolating for me being in Alabama with very few colleagues who are interested in the subject.

And I'm always not only flattered, but excited when

people enter my realm who know about the topic and I can really talk to not only about information, but about what it's been like to work so long in this field.

It can be draining at times, though most of the time when there's a successful outcome, I feel exhilarated.

And again, it's nice to share that with another person.

Yeah, absolutely.

And what I've found, you know, we're both members of this committee with the American Professional Society on the Abuse of Children.

They have a Munch House and by Proxy Committee, of which we're both members.

And I'm a member, thanks to you.

You're the one who introduced me to that group, which is a really wonderful group.

And I've noticed now in talking to everyone that

talking to several people on that committee quite a lot, including Mary Sanders and Mike Weber,

who we're also going to be interviewing for this, of course.

That committee is both about sort of knowledge and expertise sharing, but it seems like that functions in a support group way as well, because these cases are so difficult and draining sometimes, as you said.

And so that seems like that just the first time I met that group of people, too, I felt a tremendous amount of support and a tremendous amount of understanding.

And I get the sense that the professionals who are working with this need that as well.

Yes, I find working on the committee counters the isolation tremendously.

All I have to do is send an email or sign up for a Zoom call.

And I have this repository of people who

are fascinated in the same way that I'm fascinated, who want change in the same way I want change, and who want education like I do.

So it's been

exciting and very profitable

emotionally to deal with all of these experts who are coming from around the country.

So I wanted to talk to you about the various things that you're an expert of, because I think they all come into play in these stories and it's it's can be hard for people to differentiate between them.

So could you walk us through the differences between Munchausen syndrome, Munchausen by proxy, and malingering, which are your three big areas of expertise?

Right.

The umbrella term for all of those phenomena is factitious disorder.

The American Psychiatric Association, since 1980, has recognized factitious disorder as an ailment when the person induces or feigns illness in themselves.

And that's called either factitious disorder imposed on self or more commonly, munchausen syndrome.

When the person is feigning, exaggerating, or inducing illness in another person,

That's still a factitious disorder, but we refer to it often as munchausen by proxy.

And then malingering is when a person does it not for emotional gratification, but more to acquire tangible goals like money, disability payments, or other rewards like evasion of criminal prosecution or evasion of military service.

So there are subtle differences, but they're important, especially to those of us in the field, because

in some sense,

munch has a biproxy is paramount because it's a form of child abuse.

The others are not.

Okay.

And I think what we could glean even from your answer to that question is there's such a lot of confusion, I would say, around terminology with this issue, what to call it, what the sort of different terms mean.

Can you talk a little bit about

how we come to these different names and why the distinctions are important?

When I read reports about munches and by proxy, I included a table of other terms that are commonly used to refer to it.

And I think there are about 12 to 15 different terms that have been used either in the U.S., in the UK, or both.

The most familiar term by far is Munchesome by proxy.

But that's gradually changing within the professional community because DSM-5,

the psychiatrist Bible, calls munchasm by proxy, or at least the mental illness associated with it, as a

factitious disorder imposed on another.

So you can get lost in the terminology.

And that's why these days I tend to prefer the term medical child abuse, because it's so clear and it's descriptive.

You don't have to guess at what Munchausen means.

Instead, you know that this involves the medical environment in most cases and that it involves children in most cases and that it is irrefutably a form of abuse.

Do you think it's helpful?

Oops, sorry.

Sorry, one quick question.

Will you get a definition of what's the word Munchausen?

We keep using this word Munchausen.

What's that?

Oh, you mean?

Oh, yeah, that actually would be fun to talk about.

Okay, so where Munchausen,

I think probably the reason that this has stuck is because it's such an unusual word.

Can you talk about where actually the term Munchausen in Munchausen and Munchausen by proxy comes from?

A lot of people are surprised to find out that there was a real person named Baron Munchhausen who lived in the 1700s and was a military officer who retired to his estate and told

overtly silly stories about his military exploits.

He wasn't intending to mislead anyone.

He was just telling these really colorful, funny stories.

But a person who had worked probably for him or for someone close to him took his name while in the United Kingdom

and applied it to a pamphlet called basically Baron Munchausen's Marvelous Adventures.

And

the Baron found that this book was an immediate success.

It stole his name in the first unauthorized biography.

And

he was ridiculed for the rest of his life in his estate as if he had written these stories himself and had tried to present them as being authentic when they obviously were not.

That's quite an unfortunate legacy for that man to be associated with just this horrible thing now.

Yeah, Baron Munchhausen lived the last years of his life

kind of isolated and alone on his estate because he was being ridiculed so much.

I think he may have tried

a lawsuit of some sort that didn't work out very well.

He was an honorable man in the end.

And Raspi, the fellow who wrote the unauthorized biography, was not.

But his name has become synonymous with

obvious lying, horrendous lying, and it's unfair.

In 1977, a

professor who was a pediatrician applied the Barrett's name Munchausen, to Munchausen by proxy, referring to a syndrome where people didn't simply lie about illness in themselves, but lied about children who were being cared for by them.

Poor Baron Munchausen.

Justice for Baron Munchausen.

Yes.

What's interesting about the stories is they've never been out of production.

I collect books or did for a while different editions of the Baron Munchhausen stories, and I had 55

different variations

before I decided my money was better spent elsewhere.

It just continues on and on and on.

There have been at least six movies about the Baron stories, and

there's been a stage play and many radio plays.

And it's unfortunate.

It's kind of sad in a way.

And the field is moving away from using the Baron's name for the reason I suggested before, which is it doesn't really tell you what the syndrome is about, whether you're talking about Munchausen syndrome or Munchausen by proxy.

Yeah, and I struggle with the terminology because I'm being that I'm in this more public-facing space as an author and usually talking to lay people, almost always talking to lay people, I don't, I want to use the term that people know and the one that they recognize, which is Munchausen or Munchausen by proxy.

And yet I find the term Munchausen by proxy to be so problematic because it encompasses and then conflates two different things, which is, as you said, medical child abuse, which is a behavior We're not caring from a criminal aspect why someone does a thing.

We care about the behavior and the abuse and the harm.

And then it's also rolls into,

rolled into that term munchausen by proxy, is that factitious disorder imposed on another, which is the underlying psychological disorder.

And so it doesn't, it's sort of an unhelpful term in that way, isn't it?

I tend to use the term munchausen by proxy because it's so so well known.

But in doing so, I also point out that since 2013, there's been a recognized mental illness associated with munchasm by proxy abuse called factitious disorder imposed on another.

But

things may gradually change, but I anticipate that munchasm by proxy will remain the most familiar term for quite some time.

When I search even the medical literature for new reports on the subject, I search using Munchausen.

That word triggers many, many more articles today

than a factitious disorder imposed on another.

There is so much confusion.

So when people

ask you, is this

a mental illness?

When they say, is Munchhausen by proxy, which is the term people use most, a mental illness, how do you answer that question?

I tell them Munchausen by proxy is not a mental illness in itself.

It's a form of maltreatment, usually, of children.

But I also am quick to point out that the American Psychiatric Association says that

it's always associated.

with a mental illness they call factitious disorder imposed on another.

But I don't want to lose sight at any time of the fact that it's a form of maltreatment because we have a responsibility as healthcare professionals, along with some others, to make reports to child protective services and the police when we see it play out.

We wouldn't do that if it were just a mental illness, but we must do that.

when it involves the exploitation of children.

Yeah, really important.

I think something that people really struggle with understanding when it comes to the underlying psychiatric disorder, so factious disorder imposed on another, which underlies this form of abuse, with what perpetrators get out of it, why someone would do this.

That's a critical point.

We talked about malingering before, where somebody engages in behavior like this, deceptive behavior, whether it involves a child or themselves, for tangible gain.

But in Munchausen phenomena, the person is after emotional gratification,

attention, sympathy, care, support, that they feel unable to get in any other way.

Sometimes they're a bit desperate in their personal lives, and certainly

harming a child, whether it's yours or somebody else's, is an act of desperation.

And when it comes down to a possible cause for it,

what do we know about that element?

We don't know tons about the causes for someone's developing

factitious disorder imposed on another and engaging in munchausen by proxy because the perpetrators tend not to make themselves available for study.

The denial is really pervasive and persistent in these cases, and the perpetrators will, in most cases, never admit to what they've done.

And if that happens, you have no basis for exploring the behavior with them.

They're just denying there's any reason for them to be in the office with you.

That said, it does seem as if many of these perpetrators have a history of of making themselves sick.

That is, they have a history of factitious disorder imposed on self or Munchausen syndrome.

Those are fairly synonymous.

And

they also seem to have personality disorders that are very severe.

That is, they have long-term, maladaptive, unhealthy ways of trying to get their needs met.

We've heard a lot of common themes as we've been talking to people about these stories in terms of the behavior patterns.

One of them you mentioned, which is the factious disorder imposed on self.

So just a long history of inexplicable medical ailments that,

you know, I think in retrospect, people were able to identify, maybe not so much at the time.

The other things that have come up a lot are various kinds of fraud, financial and otherwise, and then infidelity.

I think in almost every case that we,

every person we've talked to for this.

so

would the personality disorder element of

of this would that kind of account for some of those other behaviors that don't seem necessarily related to factious disorders but i just are sort of patterns we've really been recognizing

i think so a common

uh

underpinning is deceptiveness and impulsivity and poor judgment.

And that kind of

person is likely to engage in all the kinds of behaviors we're talking about now, whether it's infidelity, lying about aspects of their lives that may not even involve illness in any way.

And when it's severe, we call it pseudologia fantastica, which is a

Latin term for pathological lying where the person mixes some truth with fiction, which makes for the best lie in a sense.

It's really hard to tease apart what's true and what isn't in Pseudologia Fantastica.

And

when we see that, we know that we've got an extraordinarily difficult uphill battle to fight to get them to acknowledge that anything they've said is false.

Well, and to that point, I think one of the things that can make these cases so confounding is that

oftentimes there may be some initial illness in the child or in the person if we're talking about factious disorder imposed on self there may be some illness that starts it off so it's not a matter of you need to rule out every medical thing is that right

that's so true and so important because uh doctors and and medical investigators seem not to understand that i read in academic article after academic article that these are diagnoses of exclusion.

Only when you've turned over every medical stone and thoroughly repeated tests over and over, done every test you can think of, examined the patients multiple times, they say, can you conclude that if everything's negative or inexplicable, it's a factitious disorder.

In reality, there are positive or affirmative criteria that we use, and it should be thought of and included in the differential diagnosis or the list of possibilities very early on when a patient seems not to be getting better or the history they give in the office conflicts with medical records outside.

So

part of my

difficulty as an expert in court is to make it clear that though we haven't done extensive chromosomal

assessments for some unprecedented genetic ailment to explain a child's or an adult's illness, we can still conclude that it's factitious disorder because it's not that uncommon a phenomenon.

Yes, and I want to get to the not that uncommon a phenomenon of it

for sure.

Something that had just popped into my head in terms of,

I don't know if you'd call it,

I want to call it a pre-existing condition almost, like that, that sort of the idea of there being a real health thing.

And that it is so hard to unravel lies when there are these bits of truth in them because you come across something that you can otherwise verify, and then it knocks you off kilter all over again, trying to figure out what's true and what isn't.

And something, another pattern that we've seen and that I've seen just in reading about many different cases is that many of these, the babies who end up becoming victims of medical child abuse are born premature and in some cases, severely premature.

And so any baby who's born premature is going to have some issues in the very beginning.

And something that

one of the absolute most chilling moments for me reading your most recent book, I believe this was in it.

I didn't actually actually have this in my notes because it just popped into my head, but

you did actually hear from a couple of perpetrators and talk to a couple of perpetrators for your most recent book.

And that, as you said, is really unusual.

It's very unusual to get someone who is willing to talk about their experience of being a perpetrator and willing to be held accountable.

And there was a woman that you spoke to for your book who talked about exactly how she created the scenario of having a premature birth.

And that has just something that has really stuck with me.

Do you remember which person I'm talking about?

There have been a few, and you're right, that a common

factor among some perpetrators, in fact many, is that there have been obstetrical complications

that led perhaps to a failure of bonding early on.

And so sometimes people have said there's no way this can be much as in by proxy because the mother has five children and it's only the fourth child or the fifth child that anything has happened with.

And I look at their backgrounds and find that that fourth or fifth child may well have been one of the examples in which bonding didn't really occur successfully.

Or the child is perceived as imperfect.

in some way and whether it's conscious or unconscious that child gets victimized by a mother who is dissatisfied at some level with the way things have turned out with that particular child.

In other cases, it's every child in the family.

There was a famous case in Philadelphia where the mother killed eight.

out of her ten children in a munch as a biproxy pattern.

The last two she might have killed, except they died shortly after birth and she actually had never even held them.

But

she perceived them as a weight on her life, as overwhelming to care for.

And many, many years after she had been

acknowledged to be the most unfortunately bereaved mother in America, with eight children dying, did it emerge that she had suffocated them all.

I think it's funny, even for me, these stories are

they blow your mind.

I it really, I've heard so many of them at this point, and nonetheless, still you get you get one with 10 children, and it's just it's hard to imagine.

Although, actually, it's not that hard for me to imagine at this point, I think, how this pattern sort of escalates.

Yeah, I don't know.

If you wanted me to point it out, she ended up getting a slap on the wrist

even after she confessed.

She got home confinement.

Now, she was older, and the courts thought they would, and DA thought they would have a hard time proving the case because there was no evidence left.

The last child died in 1967, the first in about 1949.

So everything rested on her confession, and they felt they had to plea bargain, and she

was given house arrest, which she violated on her birthday to go to Applebee's

to celebrate.

I mean, if you're going to violate a court's decree, is it really worth going to Applebee's?

That's the way you do it.

I guess it depends on how much you like Applebee's.

She must have loved it.

What do we know about,

if anything, the brain science?

for perpetrators like this and how it's different from other people.

And I ask because I think

it's so hard for people to understand this behavior that I wonder if you could talk about that a bit.

There has been very little research done into whether there are anatomical or physiological differences between those who engage in munches of biproxy medical child abuse and those who don't.

And we have

so little information, but based upon my 30 years of working in this field, I don't think that's going to bear much fruit.

There's never been

funding for the kind of biological research or research into heritability that we might like to see, but I think there are other priorities for any scarce research dollars we're able to come across.

There are some indications that these people have abnormalities on psychological testing or neuropsychological testing of the brain, but the results are too preliminary and nonspecific for us to point to anything and say, aha, if we test and find X, we'll know that the mother is a much housed by proxy perpetrator.

I think we're a long way off from that and may never achieve it.

I've read numerous times that it functions a bit like an addiction, which I think is a really good

comparison for me because I think we're starting to understand as a society so much better that humans can really easily become addicted to attention.

I think because we have so much data on it now because of social media companies and the way that they have monetized attention.

So I wonder if you could talk about that a bit because I...

What we have seen again sort of across the board is that it does seem to escalate.

Yeah,

there is a compulsive or addictive quality to gaining attention, even if it's under false pretenses.

And that certainly does involve false pretenses, exaggerations and falsification in these cases.

That's why I think we've been seeing an explosion of what I've called Munchhausen by Internet or Munchausen by Proxy by Internet, where a person

may

sicken their child in real life, but regardless goes online and milks social media for all it's worth by posting pictures of the child with tubes coming out of every orifice.

We call it medical porn because that's basically what it is, these disturbing photos that are intended to do nothing other than

alert friends, family, strangers that this mom needs all the support she can get.

I, yes, I think that's such a good point because obviously the internet and social media

enable this kind of abuse in a way and to an extreme that was not possible really before they existed, right?

It used to be years ago before the advent of social media that people who wanted to falsify illness had to trudge to medical libraries, find medical textbooks, decide what ailment they were going to depict,

and bring their child to the emergency room or doctor's office or hospital, or go there themselves and do a fair amount of acting to convince the doctors that there really was a severe problem when in fact there was none at all.

That's time-intensive and laborious, and it also depends on acting skill, which may not work out too well.

But now

you can become an expert in a medical illness or a mental illness in about 20 minutes by reading Wikipedia.

And you don't need to go to the medical libraries.

Similarly, you can just click to a support group of which there are tens if not hundreds of thousands devoted to illnesses of various types and they exist to be unquestionably

supportive.

In fact, it's viewed as uncool for you to question what what you're told.

You're just there to listen and provide a sympathetic ear.

And perpetrators count on that.

So they'll go online and say either that they're sickly or that the child has cystic fibrosis or asthma or some other dread condition.

And there's no verifying it, really.

That makes it hard, obviously, to dispute it, on the other hand.

And they get all sorts of attention and

feel a sense of control over other people by having manufactured all of this online.

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To your point and to the term that you coined, Mungehausen by Internet, this behavior sometimes does exist solely online.

So you've seen cases where it's women who are talking about a child that doesn't even exist.

Is that right?

That's right.

I recently published a paper where

it involved five cases in which

professed mothers who were

about to deliver or had actually just delivered talked about the child dying or suffering immense medical issues or encountering COVID.

And thorough exploration found out that these children had never existed at all.

It was all an effort to engage medical professionals and healthcare assistants.

So we always have to think about that.

I think one of the first cases of munches of biproxy by internet I ever came across did involve a college student who had no children, but made it seem as if she was having to care for five children, two of whom were sets of twins, which we commonly see in these cases,

due to, and that one died, another might die all of this was invented and false so you have to be more circumspect and less unquestioning than it used to be the case when you approach social media

yeah I think it's it's tempting for me to think about the cases that play out solely online and think well that's a relief there aren't any actual children that are being tortured and abused.

However, that doesn't mean that there isn't any damage being done because to your point, people will loop in medical professionals.

They'll loop in credulous people online who are part of legitimate support groups, where obviously if you do have a child who's medically fragile, that's an incredibly stressful situation.

And it's understandable that you would need support.

And not everyone can get support in their actual in-person community.

And so.

One would imagine that these support groups really provide a lifeline for parents who are in these real situations.

And so obviously there's an element of exploitation happening there if someone's coming in with a false story that can be extremely painful for people who get roped in.

Yes, I heard about my initial machism by proxy, I'm sorry, machism by internet cases

from victims, as it were, who believed the stories provided love and nurturance, only to have the stories start to become so bizarre that they became incredulous.

And that was a process that one person called emotional rape.

She had been spending eight to ten hours a day helping to counsel a particular parent and child,

neither of whom existed as sickly people or a sickly

person's caregiver.

And she was she felt violated.

I thought she was being a bit hyperbolic when she said it was emotional rape.

But now that I've dealt with so many people who have been victimized online, I understand that thoroughly.

That sense of betrayal, I think, is very real and can be deep.

As we now know, online connections are not

real.

I think that people do get very emotionally invested in their online friendships and

online relationships.

So that would make a lot of sense to me.

How do you think we should be approaching these spaces as

in a responsible way?

Because I know for me, if I see someone posting pictures of a sick child, or if I see someone even posting pictures of themselves in the hospital after pregnancy loss, it's not that I question that person's right to share those things online.

I personally can't interact with it.

But I wonder how should we be

approaching people who

share

these kind of things online?

We have to recognize that though it's not rare, munch hasn't by internet is still uncommon compared to all the people who go online seeking legitimate support.

So I wouldn't want all the supportive individuals out there to get a jauntist eye and think I can't trust anything I'm being told.

So I think it's best to come from a position of wanting to assist if you can and if you feel motivated to do it.

But I've also published a list of the risk signs that you're being misled online.

That was back in 2000.

And those criteria have been studied by other researchers and found to be valid.

So I would encourage readers to perhaps, I'm sorry, listeners to perhaps take a look at some of those

risk factors and see if they apply in a given case.

Is that in your

Guardian piece, Mark?

Yes, it is.

Yeah, okay.

We can definitely add a link to it.

It's in my original article, but it was reused in a Guardian piece I composed as an op-ed at the request of the Guardian newspaper in the UK.

Yeah, I think that might be the most accessible place because we would definitely want to, because that was kind of going to be one of my next questions.

Okay, let me circle back here to my, this is so fascinating, all of it.

Okay, so just to switch tracks here a little bit, so you are by far the most visible expert in the media.

And to your point that we met through a writer from New York, I was really familiar with your work already.

Your work was the only thing that I could find when my family was first confronting this issue.

Can you talk a bit about

why you are so open to talking to the media and the role that the media plays?

Well, I'll tell you a secret that may have been obvious as this interview proceeded, and that is that I don't especially love talking to the media.

I went to medical school and we were trained to talk to patients and colleagues.

But I recognized very early on that there was such a societal knowledge deficit that I literally had a responsibility to say yes to virtually every interview that someone requested because all of my publications have been in medical journals and perhaps 15 people

unfortunately read those journals and take an interest in my article within the journal but I can reach thousands, hundreds of thousands, even millions, depending upon the publication or website by talking with the media about my experiences and about what we need, we know to be true these days about Munchausen syndrome and Munchausen by proxy.

So I always do it despite my discomfort at times in doing it.

Well, I think you do great.

We've done a lot of interviews together at this point, and I always think you're great.

Yes, we have.

You're great.

Obviously, the

narrative in the media about medical child abuse, munchausen by proxy is not monolith.

But can you talk about where it stands

right now?

What is the media sort of getting right about this and what are they getting wrong?

When there is a particularly hair-raising case that police are investigating, the media tend to do a good job, it's slightly sensational, about highlighting the reality of Munchasm by proxy and the effects on people who have been drawn in by the deceptions and the effects, of course, on the child.

But it seems to be cool these days to try to debunk the reality of Munchausen by proxy.

And I think the reason for that is

the perpetrators who falsely claim that they have been falsely accused can go to the media.

and hire crusading lawyers and advocate for for themselves with government officials.

And that can be very appealing for, say, a journalist who wants to make a mark by exposing what he or she considers to be munchausen by proxy accusations run wild.

These cases of false diagnoses or mistaken diagnoses are very few and far between, but the public is getting the impression that more often than not, doctors are rushing to judgment and that is a terrible disservice to the field and to the children who can't advocate for themselves.

So if you could debunk the debunking for us,

what would you say to people who say

this isn't a real thing?

Fortunately, it's getting a little bit more common for people to acknowledge that it exists, but we get into conflict over how common it is.

One of the biggest myths is that munches and biproxy is extremely rare and I counter that it's not rare it's just we're failing to recognize it.

that if doctors and health professionals and the public were better informed about munches and by proxy, we might see an explosion of cases, not because people are suddenly abusing their children, but because we're now recognizing the risk factors for cases.

So again, it's not true that it's very rare.

It's also not true that

people who engage in munchasm by proxy abuse, the perpetrators, are, quote, crazy.

If they were, if they were flagrantly psychotic, we would be able to tell right away that they're not credibly reporting on the child's symptoms.

The fact is that even in court, they present as utterly normal people, loving parents, for whom this kind of behavior would be totally alien.

So we can't tell from just chatting with an alleged perpetrator whether or not she is in fact a perpetrator based on the apparent normality of her responses to questions.

I think also another myth is that

Munchasm by Proxy is about financial gain.

So that if somebody is not getting disability support or opioid medications as a result of what they're doing to their children, it can't really be munching by proxy.

That's a complete misunderstanding.

We call that malingering by proxy

or just plain malingering.

And as we've talked about before, the aim there is to acquire attention, sympathy, and concern.

They want intangible satisfaction and they get very deceptive in order to obtain it.

That's what Munch Hasm by Proxy is all about.

I really like that point you made about them not seeming crazy, because I think that

that is one of the

things that has persisted a bit in some of the media around it.

And I'm thinking actually more of the dramatization.

So things like sharp objects in the act, where in some ways those perpetrators come across as so obviously creepy that it does

run the risk of making it seem like this is something that anybody would be able to spot.

And that, you know, these women are so, so odd and so sort of either have, you know, this really heavy sort of southern gothic creepiness or, you know, or seem

sort of deranged,

when in fact, that's not usually the case.

And that's actually what enables them to pull this off.

Is that right?

That's precisely the case.

That's exactly what I'm talking about.

And much as a biproxy is an inherently dramatic phenomenon.

And I don't think programs like the

ones you've mentioned need to go and sensationalize it further.

When you find out the facts of a case, your jaw drops.

So why elaborate

all sorts of turns and spins to something that's so disquieting to begin with?

But it's done for dramatic effect in many of the programs that have recently appeared, in which Munchasm by proxy is either the central plot or a subplot.

Yeah, that's right.

And to your point, I think that these stories are incredibly dramatic, and

it's hard for people to wrap their heads around.

And something that I think about a lot is,

you know, it's a word that comes up all the time when you're reading about these cases in the news or, you know, reading about sort of the coverage of it in the media in any way, is the word monster, right?

So that's something that people default to a lot.

And even in one of Hope Yebara's interviews that she did from prison, she described herself as a monster.

And I

understand that because the behavior is monstrous.

I think that it's something that as a behavior, it's the worst thing that most people can possibly imagine is a mother who would torture her child in this way for the purposes of attention.

And yet I think that people

have a desire to distance themselves from it by saying that person's a monster, that person's crazy.

And in that way, it allows them to push it away and say, this would never happen in my family.

If it did happen in my family, I would be the person who knew right away.

I would not be the person who got conned for 10 years.

And I don't think that that reflects reality at all.

I think that plenty of good, smart, loving people, actually people who are good and loving, get pulled into these

stories.

And

I think that

in many ways to characterize these women as somehow this really scary other

is a disservice because in reality, I think it is the mom next door.

It is your sister your auntie your friend it could be in your family it could be in any family

when i've been interviewed by the media i actually have one example where

the

person associated with the tv show wanted to record me saying these are not mothers these are momsters

momsters

I wouldn't say it because it feeds exactly into the phenomenon you're talking about.

These people are around us.

We don't recognize them in many cases.

They appear normal, as we've talked about.

And so whoever says that it should be evident from uncontrolled behavior and wild emotional reactions is just not understanding what the phenomenon is about.

These people tend to be master deceivers and manipulators, and they manipulate even the smartest among us, like doctors.

They do that routinely.

So we have to get off our high horse and get away from the notion that we can, just through the force of being perceptive human beings, tell when munches of biproxy is involved and when it is not.

And I think almost the sort of idea of like

you could tell by being around that person, by looking at that person, sort of the obvious craziness.

And I wonder if you could talk about, you have testified in court many times as an expert.

Can you talk about the role of

an expert such as yourself and the role of psychological evaluations in these cases?

Well, often I'm retained by a father in a custody dispute.

And

the other side is vicious.

The mother side, when it involves a person I've identified as a true Munchausen by proxy perpetrator,

attacks me.

They attack me personally.

I've often been on the stand for as long as seven hours as they grill me about anything they think they can possibly come up with, including very personal questions that I'm happy to answer, but they obviously hope I'll say something incriminating.

It can be frustrating, but I'm going to continue to do it.

It is hard at times to sit that long and face ill-informed, if not openly malicious questions

about one's character, etc.

But there's really no other defense.

I sometimes cut to the chase when I'm testifying and say that this is child torture, because the word torture

gets attention and it also points to the reality.

of the phenomenon, at least in some cases, where repeatedly bringing a child to the brink of death and then bringing the child back only to do it again is a true case of torture.

So I don't feel like it's hyperbole to use that term in court or when you're talking about the phenomenon.

Again, depending upon the case you're really referring to.

Right, because of course this behavior can encompass a huge range of

activity, right?

This can be all the way from, as we discussed, the child doesn't exist and this is only happening online, or the children children do exist, but they're not actually imperiled physically to women who kill their children.

Yes, there's a continuity, not a discontinuity between normal and abnormal in many psychological phenomena and abuse phenomena, and that includes munchausen by proxy.

For example, one of my challenges when I'm exploring a case is to find out if the mother is, in quotes, merely over

or willfully abusive.

And one of the differences is that the mother who's over-anxious will be reassured and happy when she's told that results are negative.

The munch has a biproxy perpetrator feels like they may be at the end of the line and that their lies are going to be discovered.

So they are upset and demand further testing, including surgical procedures that they know at some level aren't truly needed.

So there is some continuity there there that we have to recognize.

It can be especially difficult to tease apart when the child does have some kind of real medical ailment that's combined with exaggeration

or some limited induction, because then we are sort of straddling a fine line between what's true and what isn't.

But I find that I can almost always make the determination with a reasonable degree of medical certainty.

So if I thoroughly review all the information that can possibly be acquired in a given case and reviewing it with a very close eye and with an educated eye.

And a lot of this does come down to reviewing evidence, right?

It's not something where

I would imagine you could sit down with someone isolated from any looking at any of that paperwork and just say, oh, this person does or does not

have factors to sort of impose on another.

That's so true.

And judges don't understand that point.

So, one thing I'm seeing frequently these days is judges who order a psychological evaluation of a mother who's been accused of medical child abuse, saying

that's all they really need to see to establish the truth or dishonesty.

They

often don't order or even request a thorough review of the medical records, which is the real way you make the diagnosis.

And yet I hear from people saying, I need to find a psychologist expert in this area to do psychological testing of this mother because the judge ordered it and won't consider anything else.

So one of the big goals that some of the members of the American Professional Society on the Abuse of Children have is to

hone in on family court judges as an audience that needs to hear what we have to say about what's proper diagnosis and what is a wild goose chase.

And do you feel family court judges in general have a good understanding of this kind of abuse or not?

Not at all.

There are refreshing exceptions, but there are relatively few exceptions.

I find that they don't take it very seriously and tend to weed out penalties that are nothing more than slaps on the wrist.

If they offer any penalty at all, often they'll deny the mother, even when she's been overtly and obviously abusive,

a kind of deal.

where they'll take the child and remove custody, place the child with someone else, but there's no other penalty on this mother who has almost killed her children.

They tend not to be criminally prosecuted.

They're handled in family courts, and that's been a frustration for me.

You were talking about how

one of the current narratives going in the media is this idea of

false accusations.

And

how prevalent do you think false accusations are?

I think that's something that really can cut to people's emotional core really easily because parents will look at these stories and think, what if my child were sick and I was trying to seek treatment and I got accused of abusing my child because I was advocating.

I actually did some research with a colleague named Dr.

Deirdre Rand about 20 years ago looking at this very question.

And what we did was survey the world literature, but also the lay literature, looking for reports of people who had claimed or been proved to have been falsely accused.

We found the percentage to be about 2%.

So out of 100 cases, 98 were valid and 2%

were falsely diagnosed.

That has me not worrying so much about the false accusations, but worrying a great deal about the identification that we're missing in so many cases.

There's an extremely high incense of female perpetrators for this kind of abuse.

I think it's somewhere around 96%.

Why is that?

To some extent, to a very large extent,

medical child abuse is a crime of opportunity.

And in every society I'm aware of, mothers tend to be the primary caregivers of children.

So they have an access and credibility with doctors and others that fathers may not have.

And in fact, in these cases, the fathers tend to be very distant or entirely absent.

The father may not be involved at all with any of the medical visits, feeling that that's the domain of the mother.

to handle anything medical that arises.

They may have very traditional families where they view themselves, the men, as the breadwinners, but not somebody who would really be involved in treating,

taking a child for treatment.

I think the issue of its being a crime of opportunity helps explain why 96 to 97% of all perpetrators are in fact a female, specifically the victim's mother.

Should we think of this underlying disorder, a factitious disorder imposed on another, as something that is treatable?

Another myth that I've labored with is that it's readily treatable.

It may be treatable in a small minority of cases, but all the current treatment models depend on the assumption that the mother will agree that she in fact has been a perpetrator.

Treatment takes off from that point.

If the mother has really recalcitrant denial, she's going to disagree with you about why why she even needs to be in the office with the therapist and you can make very little progress.

So I have come across

perhaps in my career a couple of cases where treatment was successful and where I felt optimistic up front.

But you never know until the hurdles are jumped and the mother proves that this is now alien.

behavior for her.

She understands what she did wrong.

She has a support network.

She may have attended parenting classes and learned how to care for other people in a variety of mechanisms.

And then I have been able to recommend reunification.

But I think there's again only been a couple of cases in 30 years where I could do that.

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