Bonus: Unabridged Conversation with Dr. Marc Feldman 01:03:14

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 the best known munchausen by proxy experts in the world and

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. He's the most terrifying serial killer you've never heard of. Haddon Clark has confessed to several murders, but investigators say he could have over 100 victims. At the center of the mayhem, a cellmate of Haddon's that was able to get key evidence into Haddon's murder spree across America.

As you may know, we have a little bit of a

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M-A-R-C Feldman, F-E-L-D-M-A-N-M-D, and I'm a 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 therapy.

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 and

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, and much as in 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

of this committee with the American Professional Society on the Abuse of Children. They have a Munchausen by proxy committee, 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 that committee is based

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

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 munchasm 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, munchism by proxy is paramount because it's a form of child abuse. The others are not. Okay. And I think what we can 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 write reports about Munchausen by proxy, I include 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 US, in the UK or both.

The most familiar term by far is munchausen by proxy, but that's gradually changing within the professional community because DSM-5, the psychiatrist's bible, calls munchausen 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 a 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 the word Munchausen? I keep using this word Munchausen. What's that? Oh, you mean like... Where did that come from? 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 Munchausen 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 publication.

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.

Yeah, Baron Munchausen 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 Raspy, 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,

Professor, who was a pediatrician, applied the baron'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.

He's he's it was 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 Munchausen stories and I had 55

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, 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 carrying from a criminal perspective.

aspect why someone does a thing where we care about the behavior and the abuse and the harm. And then it's also rolls into rolled into that term unchosen 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 well known. But in doing so, I also point out that since 2013, there's been a recognized mental illness associated with Munchausen by proxy abuse called factitious disorder imposed on another person.

But things may gradually change, but I anticipate that Munchausen 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 factitious disorder imposed on another person.

There is so much confusion. So when people ask you, is this a mental illness? When they say, is Munchausen 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 another child, 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 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 factish 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've, every person we've talked to for this. So would the personality disorder element of this, would that kind of account for some of those other behaviors that don't seem necessarily fraudulent?

related to factitious disorders, but just are sort of patterns we've really been recognizing? I think so. A common

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 Lyme 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 affective 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? Yeah.

That's so true and so important because doctors 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 experience

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 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 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 was

I believe this was in it. I didn't 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 felt

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 thing

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 a 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 Munchausen by proxy 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've heard so many of them at this point. And nonetheless, 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. 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 that 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, much as a by proxy, 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 Munchausen 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 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 Munchausen by internet or Munchausen by proxy by internet, where a person is

They 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? Yeah.

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 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 criticism.

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To your point and to the term that you coined, Munchausen 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 Munchausen by proxy 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, 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 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 it's

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 Munchausen by proxy, I'm sorry, Munchausen by internet cases from victims, as it were, who believe the stories provided love and nurturance, only to have the stories start to become so bizarre that

that they became incredulous. And that was a process that one person called emotional rape. She had been spending eight to 10 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 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, you know, 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, munchausen 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 jaunt to stye 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? It's, it's, yes, it is. Yeah, okay. Yeah.

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 was – 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

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 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. 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 care-raising case that police are investigating, the media tend to do a good job, if slightly sensational, about highlighting the reality of Munchausen 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 perpetrators.

crusading lawyers and advocate 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 Munchausen by proxy 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 Munchausen 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 Munchausen by proxy abuse, the perpetrators, are "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 Munchausen 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 munchausen 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 has on my 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 changed.

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 seem

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? Yeah.

That's precisely the case. That's exactly what I'm talking about. And Munchausen by proxy 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.

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 the fact that these stories are incredibly dramatic.

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 Ybarra's interviews that she did from prison, she described herself as a monster. And I agree.

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 people

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. It's just not understanding what the phenomenon is about. These people tend to be mastered 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 manipulate

just through the force of being perceptive human beings, tell when Munchausen by proxy 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, 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 is

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 do exist but they're not actually imperiled physically, to women who kill their children. Right.

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 overanxious.

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 munchasm by proxy perpetrator feels like they may be at the end of the line and that their lives 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 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 that

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 set or impose on another. Right.

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 home 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

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 instance 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 it's being a crime of opportunity helps explain why 96 to 97 percent 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 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.