Nobody Should Believe Me - Bonus: Unabridged Conversation with Dr. Marc Feldman

Episode Date: April 20, 2023

In today's bonus episode, we share Andrea's unabridged conversation with Dr. Marc Feldman, one of the experts we heard from throughout season one of the show. Dr. Marc Feldman is a Clinical Professor of Psychiatry at the University of Alabama,Tuscaloosa and an internationally renowned expert on Munchausen by Proxy. He is the author of five books, more than one hundred peer-reviewed articles, and has appeared as an expert in dozens of television programs, print media, and documentaries throughout the world. Dr. Feldman is a longtime member of the APSAC’s MBP committee and originally nominated Andrea as a member.    More about Dr. Feldman:  https://www.munchausen.com/  Munchausen by Proxy is a serious and widely-misunderstood form of child abuse. It can result in a wide swath of destruction and trauma for everyone involved and lifelong devastation for survivors. Munchausen Support was created in collaboration with some of the world’s top experts and provides science- and fact-based information about Munchausen by Proxy. It is also intended to offer resources and support for professionals in the midst of a case, family members in crisis, and survivors seeking treatment. https://www.munchausensupport.com *** Click here to view our sponsors. Remember that using our codes helps advertisers know you’re listening and helps us keep making the show! Buy Andrea's books here. To support the show, go to https://apple.co/nobodyshouldbelieveme  to listen on Apple Podcasts and just click ‘Subscribe’ on the top of the show page to listen to exclusive bonus content and access all episodes early and ad-free or go to Patreon.com/NobodyShouldBelieveMe. Learn more about your ad choices. Visit megaphone.fm/adchoices

True Story Media. 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 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 Webber 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. Well, friends, it's 2025. It's here. This year is going to be, well, one thing it won't be is boring. And that's

about the only prediction I'm going to make right now. But one piece of news that I am excited to share is that the wait for my new book, The Mother Next Door, is almost over. It is coming at you on February 4th from St. Martin's Press. So soon! I co-authored this book with friend and beloved contributor of this show, Detective Mike Weber, about three of the most impactful cases of his career. Even if you are one of the OG-est of OG listeners to this show, I promise you are going to learn so many new and shocking details about the three cases we cover. We just go into so much more depth on these stories. And you're also going to learn a ton about Mike's story. Now, I know y'all love

Detective Mike because he gets his very own fan mail here at Nobody Should Believe Me. And if you've ever wondered, how did Mike become the detective when it came to Munchausen by proxy cases, you are going to learn all about his origin story in this book. And I know we've got many audiobook listeners out there, so I'm very excited to share with you the audiobook is read by me, Andrea Dunlop, your humble narrator of this very show. I really loved getting to read this book, and I'm so excited to share this with you. If you are able to pre-order the book, doing so will really help us out. It will signal to our publisher that there is excitement about the book, and it will also give us a shot at that all-important bestseller list. And of course, if that's simply not in the budget right now, we get it. Books are not cheap.

Library sales are also extremely important for books, so putting in a request at your local library is another way that you can help. So you can pre-order the book right now in all formats at the link in our show notes. And if you are in Seattle or Fort Worth, Mike and I are doing live events the week of launch, which you can also find more information about at the link in our show notes. These events will be free to attend, but please do RSVP so that we can plan accordingly. See you out there. Calling all sellers. Salesforce is hiring account executives to join us on the cutting edge of technology. Here, innovation isn't a buzzword.

It's a way of life. You'll be solving customer challenges faster with agents, winning with purpose, and showing the world what AI was meant to be. Let's create the agent-first future together. Head to salesforce.com slash careers to learn more. Yeah, my name is Mark 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, 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 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 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 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 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. 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, munchism by proxy is paramount because it's a form of child abuse. The others are not. 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 munchasm by proxy, but that's gradually changing within the professional community because DSM-5, the psychiatrist's 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 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? Sorry, one quick question. Will you get a definition of the word Munchausen? I keep using this word Munchausen. 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 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 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 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, a 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. 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 Munchausen 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 Barron 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 caring from a criminal aspect why someone does a thing or we care about the behavior and the abuse and the harm. And then it's also rolled into that term Munchausen by proxy is that factitious disorder imposed on another, which is the underlying psychological disorder. And so 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. 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 searched 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 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 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 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, 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 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 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 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? 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 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 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 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 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 10 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 I these stories are they 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 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 munchausen 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 it 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 may sicken their child in real life, but regardless goes online and milk 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. The internet and social media enable this kind of abuse in a way and to an extreme that was 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 feel a sense of control over other people by having manufactured all of this online. When it comes to reaching your goals, personalized advice and performance matter. And now you can get $300 when you invest with RBC. Offer ends March 3rd, 2025. Terms and conditions apply. Invest with RBC today. Playoff football is here with BetMGM. And as an official sportsbook partner of the NFL, BetMGM is the best place to fuel your football fandom on every game day

with a variety of exciting features. BetMGM offers you plenty of seamless ways to jump straight onto the gridiron and to embrace peak sports action. Visit BetMGM.com for terms and conditions. Must be 19 years of age or older. Ontario only. Please gamble responsibly. Gambling problem?

For free assistance, call the Connex Ontario helpline at 1-866-531-2600. BetMGM operates pursuant to an operating agreement with iGaming Ontario. I want to tell you about a show I love, Truer Crime from Cilicia Stanton. My favorite true crime shows are the ones where I feel like the creator has a real stake in what they're talking about. And this is definitely the case with Cilicia, who got interested in covering crime because, like many of us in this genre, she experienced it. In each episode of the show, Cilicia brings a personal, deeply insightful lens to the crime that she covers, whether it's a famous case like the Manson murders or Jonestown, or a lesser known case that needs to be heard, like the story of a

modern lynching. She covers these stories with a fresh and thoughtful lens, helping listeners understand not just the case itself, but why it matters to our understanding of the world. Her long-awaited second season is airing now, and the first season is ready to binge. So go check out Truer Crime with Cilicia Stanton wherever you get your podcasts. 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 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 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 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 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, munchism 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 jauntous die 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. 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 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 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 munchism 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 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 munchism 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 persisted a 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 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 in many of the programs that have recently appeared in which Munch has on my proxies 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 Ybarra'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 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, 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, yeah, the obvious craziness. And I like, you could tell by being around that person, by looking at that person, sort of the, yeah, 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's 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. 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 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 overanxious or willfully abusive. And one of the differences is that the mother who's overanxious will be reassured and happy when she's told that results are negative. The munch has a 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 that 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 set or 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 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. 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 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 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 reinfection. But I think there's, again, only been a couple of cases in 30 years where I could do that.