Nobody Should Believe Me - Bonus: Unabridged conversation with Dr. Mary Sanders

Episode Date: May 18, 2023

Listen to Andrea’s full conversation with Dr. Mary Sanders, director of child & adolescent psychology at Stanford and nationally recognized expert on Munchausen by Proxy. We discuss the possibilities of treatment for perpetrators as well as the effect this abuse has on victims and how they can heal. The American Professional Society on the Abuse of Children: https://www.apsac.org/ Munchausen Support: munchausensupport.com *** 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. *** Click here to view our sponsors. Remember that using our codes helps advertisers know you’re listening and helps us keep making the show! Learn more about your ad choices. Visit megaphone.fm/adchoices

True Story Media. Mary Sanders. Dr. Sanders is a clinical associate professor at Stanford University, and she is just an incredible expert on the treatment of perpetrators in particular. So you heard from her in a couple of episodes on season one, and this is my complete conversation with her, which includes lots of fascinating stuff that ended up on the cutting room floor. If you are interested in more content like this, you can join our Patreon. We have a really great community building over there. And there are many episodes that will never make it to the main feed, such as my complete interview with Hope Ybarra, which trust me, that is a fascinating one. I hope you guys enjoy this episode. We are hard at work on season two and hoping to bring that to you in early spring.

That is going to be a second case, another Mike Weber case from Texas, completely different type of story than the Hope You Borrow story, completely different type of offender. Lots of interesting new angles. I think it's a fascinating and ultimately hopeful story. So I'm excited to bring that to you. We're also going to be looking at just some other sort of elements of

the systems around this issue and some more of my own story. So keep an eye on your feet. And now here's my conversation with Dr. Mary Sanders. 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.

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Let's create the agent-first future together. Head to salesforce.com slash careers to learn more. Hi, I'm Dr. Mary Sanders. I'm a clinical associate professor at Stanford University Medical School in the Department of Psychiatry. I'm also co-chair of a national committee through APSAC, the American Professional Society on the Abuse of Children. And the committee is a multidisciplinary committee that looks at the assessment and treatment of Munchausen by proxy. So yeah, let me start with the accepts model. So treatment of perpetrators

of Munchausen by proxy abuse is very difficult. The perpetrators tend to engage in denial, both to themselves and to others. And what we found is that the most important aspect of treatment is being able to acknowledge that the abuse has occurred. And so we have put together a treatment model. It's called ACCEPTS, A-C-C-E-P-T-S. It's an acronym. AC stands for acknowledgement because that's really the most important first step. We need for the perpetrators to be able to get to a place where they can acknowledge that they've engaged in this form of child abuse and fully take responsibility, being able to recognize a need to put their

child's needs first above their own. The next C is for coping. We work on developing coping strategies in order to be able to help them meet their needs in ways in which their child is not being abused. E is empathy. Again, being able to empathize and recognize the harm or potential harm that they have caused to the child. What am I up to? E. So P is for parenting, working on parenting skills, also important. And T is for taking charge. A lot of perpetrators of munchausen by proxy abuse, a lot of them are mothers

and a lot of them feel very disempowered. They are getting their needs met indirectly. And what we want them to be able to do is work on recognizing their power and taking charge appropriately. And then S is for support, which is so important. Being able to build a support system in which their supports recognize, acknowledge the abuse, are supporting them in appropriate behaviors, both within the family and the community and accepting outside monitoring in order to ensure that abuse does

not reoccur. With the general question of, are these perpetrators treatable? What is your answer to that? Oh, that is a hard question. Treatment with perpetrators of Munchausen by proxy abuse is very difficult. Again, the important aspect is acknowledgement. And when individuals tend to have what's called an external locus of control, they tend to blame others, not take responsibility, get their needs met indirectly using deception. It's very difficult for them to admit and acknowledge that they've engaged in these behaviors, not only to others, but to themselves. Certainly they may face all sorts of reprisals from friends, family, and legally as well. And so there's a lot of reasons not to acknowledge the abusive behaviors. With that said, some have been able to do so.

And it takes a lot of courage for them to be able to do that. When they have, they have then been able to work successfully in treatment. We have had successful cases. We have had cases that were able to reunify with ongoing support. It is quite a process. It takes quite a long time and involves evaluation, re-evaluation of progress in order to work toward reunification. Yeah. So do you have a specific case that you could talk us through of someone who's been successfully treated in your opinion? I can. I've had a couple of cases that have been successful. And again, for the most part, it was acknowledging. I've had two cases in which the parent did acknowledge, actually fairly early on in the

process. One parent told me that they felt relief. They wanted someone to actually catch them and stop them because they felt as though they couldn't do that themselves. And then they were able to engage in long-term treatment, which also included definitely separation. They were not reunified with their children. Two of them did go to prison for a period of time, and when they came out of prison, continued the treatment. So the treatment actually spanned several years of working at

becoming empowered, taking charge, working on parenting skills. And one of them did go on and have future children as well. And they were able to appropriately parent those children. And also along with, you know, all along the way, a lot of monitoring. Do you have any insights that you could share with us on what the difference was in those cases where they were able to be successfully treated? The main difference was being able to acknowledge that was it. Truly acknowledge what they had done, truly become empathic, recognize the harm they've caused to their children. In one case, the parent was able to explain to their children a couple years later when she was able to see them what she had done, which actually helped them in their

healing as well. I have to say, it's hard to imagine having known about a lot of these cases. It's hard to imagine what would bring a perpetrator to that light bulb moment, if you will. I think we even hear a lot of stories of perpetrators that go down for long jail sentences who never acknowledge what they've done and maintain their innocence. Absolutely. And statistically speaking, that is the case. I've also worked with much more cases that did not get to that place. Right. You've talked about the difficulty of getting people to acknowledge their behavior, which

is obviously a really big lift and a really necessary first step. Are there other things that make this kind of treatment particularly difficult? Yes. A lot of the parents have engaged in their own factitious behaviors and post on self. And I have had some parents that it was very difficult for them to admit that to themselves and to their family. The families were, needless to say, quite surprised and upset and felt betrayed. Also, personality disorders. A lot of parents are diagnosed with personality disorders that are difficult to treat. And especially if the abuse has been severe and life-threatening, for example, non-accidental poisoning or smothering,

these are much more difficult situations in which to work at treatment and reunification safely. Part of what you're talking about sounds to me that it's made more complicated by the presence of this huge taboo around the topic and a huge amount of shame. And that makes me think of the comparison I've heard several times of this sort of abuse to pedophilia. And can you talk a little bit about why those two things can be similar? Yes. Munchausen by proxy child abuse has been compared to compulsive behaviors like pedophilia, even eating disorders, basically conditions in which feel very compulsive, difficult to discontinue the behaviors. I have had parents tell me that, I think, I mentioned, that basically it was, they couldn't stop on their own.

They really felt like they had to have outside intervention to stop on their own. I've had other situations and when parents have said that the excitement of the Munchausen by proxy wasn't even sort of enough. They were engaging in other behaviors that were deceptive and dangerous and like arson and other crimes. I have to ask because this came up a lot in the stories we were talking about sort of high-risk sexual behaviors, lots of affairs. We heard about lots of affairs. Is that something that you've, is that a pattern you've noticed or is that just? Yeah, I can't say that I've had enough perpetrators that have been open with me to

even talk about that kind of pattern, but I have had that same history given to me as well. So I did want to talk a little bit more about the idea of reunification in these cases, because, you know, something that I've heard talking to people about family court is that usually the goal of family court, which is where a lot of these cases end up rather than in criminal court, you know, is to reunify the family. That's usually seen as a successful outcome. So I wonder how we should think about whether or not reunification should ever be the goal in these cases, and if so, under what conditions? It is a great question. Reunification is a mandate, as you mentioned, of child protective

services. And we do want to try to do that if possible, obviously, if it's safe for the child. It is quite a process. As I mentioned, the first step is going to be acknowledgement from the perpetrator that the abuse has occurred. Along the way, also, if the spouse is going to reunify, the spouse has to also accept that these behaviors have occurred and recognize that they're going to be an integral part in providing protection and support ongoing. And then the children too. Obviously, depending on the age of the children, as I mentioned, that basically we

want to be able to have the children informed as well. And so if in fact treatment with a perpetrator can be successful, treatment with a non-abusing spouse can be successful, then we're at the stage of being able to have a parent inform the child of the abusive behaviors that he or she engaged in and be able to set up a extremely important safety situation, usually in which the non-abusing spouse is the one that takes the child to the doctor. The doctors are informed. We usually request that there be two pediatricians that are informed, and they're the gateway to any treatment that the child needs. And if that pediatrician retires and the next one is informed. And so there's basically a lot of checks and balances to maintain safety within the family. With all that said, that's a lot. And so it takes a lot

of energy, a lot of dedication for these families to work toward reunification. It has been successfully done. It is very rare, though. So it sounds like what I'm hearing you say is that it really takes not only acceptance from the perpetrator, but acceptance from really that parent's entire community, really. Absolutely, yes. And the support. Do you, do you see a lot of difficulty with non-offending spouses and relatives of the perpetrator and sort of, do you see people having a lot of trouble accepting

this, you know, disorder and accepting this behavior? Absolutely. And as a matter of fact, if, so when a child is removed from the alleged perpetrator, certainly what we want to do is be able to place them with family. So those family members, non-abusing spouses, extended family, absolutely need to be able to acknowledge the abuse. And yes, there's many situations in which the family members have not been able to do so, unfortunately. And so in that case, if the perpetrator, even if the perpetrator accepts it, do sometimes the family members still not accept it? Or is that kind of a, if the perpetrator turns, does everybody turn? Or I'm curious.

You know, I don't think I've ever had a situation where the perpetrator was accepting and the family didn't. That's an interesting, it may be out there, but I just don't know about it. I'm so curious. And I think a lot of people are curious to hear from someone who's engaged in these behaviors, what that experience is like for them, you know, how much they understand about what they're doing, whether or not they ever get convinced of their own deceptions, that kind of thing. Absolutely. Yes. So those perpetrators that have been able to acknowledge and open up about their experience, I guess, let me go back a little bit. Sometimes that isn't the case right away. And it may take us a little bit to get there. And my approach in

working with perpetrators is to look at their, to help, we go back in time and look at their growing up, you know, how they grew up, especially around how do you get attention? How did you get your needs met? And sometimes in doing that, what we've been able to do is discover almost this story in which they realized they had used deception in their childhood to get attention. And they may have even seen, you know, the child that pretends to be sick to stay home from school, right? That's, you know, a number of us have done that. But, you know, they may have seen this and been a part of that themselves in a more significant way or seen it in their family system. And basically that sometimes helped them be able to acknowledge, wow, this is really, I've done this. I've engaged in these behaviors in my life. And now I've taken it

to this step where I've, you know, presented myself as being ill when I'm not, presented my child as being ill when my child is not. And so sometimes that's where we can get to the acknowledgement if it's not right away. With that said, going further into acknowledging and, you know, how, what happened to that knowledge that you were doing this? And what I've been told on a couple of occasions is that there's a defense mechanism called compartmentalization. And one parent told me they were able to take the knowledge they had, were doing this to their child, actively harming their child, and sort of put it in a little mental drawer and kind of close it, you know. So sort of put it aside. They knew it was happening, but they could just not pay attention to that information. You know, and every once in a while, they would see,

you know, like you lose your keys and you know, there they are, you know. So every once in a while, they would be reminded that they were engaging in these behaviors. But they would also be using rationalization and other defense with the idea being that, you know, this is helping my child. They're getting these opportunities to meet celebrities or, you know, Make-A-Wish Foundation, Habitat for Humanity built my house, you know, so rationalizing that somehow this was actually in their child's best interest. And I have had parents that did, they said they almost came to believe, you know, the illness, you know, sort of like if you tell yourself a story over and over, you do tend to kind of, you know, buy into it a little bit. And especially when the doctors, you know, when they were able to convince doctors and then the doctor said, oh yes, your child has this, you know, they were able to kind of suspend reality and come to believe it to some extent themselves. That's really interesting. I think that the

experience that a lot of people who've been adjacent to these cases will talk about, you know, family members and that kind of thing is this experience of they seem so convinced of this when they're telling me, you know, that the person when they're reporting these things that turn out to be false, what they just seem like they believe it. And so that that holds with with what you're saying. And of course, that's distinct from being delusional, right? They're not actually sort of believing these things in the way that someone who's having delusions believes them to be true or someone that's an extreme hypochondriac or something like that believes. They don't actually believe their child's ill, but they're creating such a compelling alternate version of reality that there are moments that they're sort of slipping into that version of reality. Is that sort of what you're explaining? Yes, it's beautifully said, exactly. Yes, it's not a delusional system, but just being able to kind of, you know, almost convince themselves, even though they know it's not true. conception when people are looking at these cases to look at these perpetrators as monsters

and to just think this is a person that if they if you get people across that bridge of believing that it's happening then I've found that sometimes the only way people can then cope with that is by saying oh this is just a monstrous human you know that word monster comes up a lot. And I really appreciate and think it's extraordinary that people like you can find enough empathy as a way in to helping these women and helping these families. And it's moving for me to think that, you know, to think that it's not just completely hopeless. I think it's important that we, it's important that we emphasize how difficult it is and how many things need to be in place. But, you know, I think, I don't think that it helps us as a society to put these perpetrators in a box and sort of throw away the key. Do you know?

I absolutely agree. And I've had people tell me that. How can you do this work with these monsters? You're right. I've had I've had that word used quite a bit, actually. And I think it comes from seeing, you know, experiencing and acknowledging that, you know, we are not defined by our behaviors. We are multi-storied. Certainly, we can all engage in behaviors that don't fit for us. We can engage in behaviors that can be altered, you know, with support and help. And recognizing, especially the parents that I've worked with that were successful,

these were very disempowered women. And one of the moms I worked with, you know, was through her work became so empowered. So appropriately, personally empowered. She actually became CEO of company. This was a stay at home mom that felt very stuck. And, you know, she was very brave in taking on the treatment, you know, being out there with her experience and moving forward in her life. Yeah. I, I, I know which story you're talking about. And I really, that was such a fascinating story to me. I, I didn't think, I didn't think that that

was a possibility. And I think it is inspiring to think that there's something that could be built on that could help. So you can say, you know, and you get taken care of. And I think everyone can relate with that experience. I think there's a pretty universal human experience to enjoy being nurtured and taken care of and having a little minute from, you know, from away from life. And I think especially, you know, harried moms can definitely relate with that, right? So I think it's really helpful to bring those comparisons back down to earth a little bit, because I think that the more that we can understand how this is an extreme of that feeling that we can relate with, and the same thing, you know, so much of these behaviors now in modern day cases really manifests online. And I think we're having getting a much better understanding of the culture about how, you know, the attention economy works online and how

getting attention for a post and how getting likes and comments and feedback really feeds something in our brain. And that's not just people that have a disorder. That's all of us. And so I think it, to me, I think it's helpful to everyone to understand that this is on a continuum rather than a good mother does this and a monstrous mother does that. Right. It's not an all or none. Exactly. Yeah. And there is a pretty big spectrum of these behaviors. Is that right? Spectrum as far as... Just in severity, like sort of from people who are mostly keeping their activities online to people who are really, you know, as you said, poisoning, suffocating their children. You know, there certainly is a spectrum. With that said, we're also very cognizant that even, quote, milder, you know, where there's not induction of illness, there's maybe just

falsification of illness. However, all of this is harmful to children. And we do want to keep that in mind. And I think it's especially important because the best way to get these families help is to report the abuse. And I also wanted to say that there's another term called medical child abuse, and it refers to situations in which children may be over-medicalized, brought to the doctor when they may not have a need. And we may not know whether there's falsification intentional or not. This may be an overly anxious mother or a delusional parent, but still the child is being harmed. So we do want to acknowledge that we want these cases, the best thing is to be able to report and intervene. And yes, there is a spectrum of abuse from sort of just falsifying, saying a child has seizures when they don't, et cetera. However, that leads to inappropriate treatments that can be harmful, evaluations that can be invasive, all the way to, yes, smothering or use of substances, poisoning that can certainly put a child at risk for death. I'm really glad you said that. And I think it's important for people to understand that

the damage done to the children is not purely physical, right? So could you talk a little bit about some of the things that victims and adult survivors struggle with? Absolutely. Yeah. So when children grow up believing that they're ill, that's their life, that's their self-story. And that means that they may be missing school. They may be missing social opportunities, developmental opportunities. I've had kids, even after the abuses come to light, they don't know. They still believe that they're ill. They grew up with this self-story of very hard for them to move from it. A couple of kids that I work with that had falsified allergies, very fearful of trying

some of the foods that they were told would harm them or even lead to death. And so, yes, the self-story of, of illness can be very difficult to debrief the kids from. And, you know, so, so basically that's the, you know, the main issue of just all the, all the, the whole, whole life around being ill. And then suddenly everything's changed and they're being told they're not ill anymore or all these things maybe didn't exist. And it's very hard to sift through for them and sense of betrayal. And post-traumatic stress sometimes if they did know.

Some of the kids were aware that they were being abused and felt that they were being abused and felt that they couldn't fight back. So that lack of control too. And to talk a little bit more about the sense of control or lack of control, I think it was in one of Brenda Bursch's papers that I read that she compared these perpetrators to being almost like cult leaders and that survivors often need to go through a similar sort of deprogramming. You just called it debriefing. I wonder if you could, that comparison felt so apt to me. And I wonder if you could just talk a little bit about that sort of overarching piece of this that's sort of the child's entire

life and not just this one segment of their lives having to do with medical stuff. Sure. And I get asked a lot about why would children collude with their parents. And, you know, a lot of times these perpetrators are very convincing and very strong in their opinion. Sometimes they're crusaders. They're out there crusading for their children, apparently, you know, for treatments. We've had several cases that have met with first ladies, Hillary Clinton, Nancy Reagan. You know, so this is, you know, that's a big time. And it's really difficult to, as the kids sort of grow up in this culture in which this is what we do. It's very difficult to kind of challenge that, especially if they've grown up in it. I know,

you know, the case of Gypsy Rose Blanchard. I mean, basically that went on well into adulthood. You know, the victim was an adult before things came to light. And so, yeah, it's very hard for them to fight back. I had one situation in which a family that I was working with, they had actually seen a special on Munchausen by proxy. And they came to the doctor and I was there the next day. And the kids in the family had empowered themselves to tell the doctor that they felt this was going on because they now had a name for it. And so that was a very rare event that, as you can probably tell from the literature, does rarely happens.

And were they believed? They were because we were suspecting it as well. And actually, it was very, very helpful in helping the parent be able to acknowledge because the kids put it out there and the parent was able to acknowledge. And it sounds like these kids were minors when this happened. Oh, yes. So I'm wondering in terms of for adult survivors, do they usually eventually realize that they've been the victim of abuse? You know, since I've been in the field since the 80s, it's been interesting to see the field grow so much. You know, way back, there wasn't much out there in the public about this.

There weren't names for this type of abuse. And so these victims really didn't feel like they had a place to go. And now they do. And so, yes, victims have come forward in their adulthood and been able to talk about their stories, recognize what had happened to them. I've worked with a few and some have been able to get their medical records and be able to kind of sift through and themselves and look at the story of illness that was falsified over time. Some have been able, I guess, actually, if I think about the ones that I'm aware of, most have been able to confront their parent. But I don't think any of them have had a parent that had, that I'm aware of anyway, that had a parent that was able to acknowledge.

Which, yeah, I can only imagine how frustrating that would be for, as a survivor. Okay. Let me just. Like so worried about my sister. You're engaged. You cannot marry a murderer i was sick but i am healing returning to w network and stack tv the west side ripper is back if you're not killing these people then who is that's what i want to know starring kaylee cuoco and chris messina the only investigating i'm doing these days is who shit their pants killer messaged you yesterday this is so dangerous i gotta get out of this. Based on a true story.

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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. 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. Yeah, I don't know. Mary, are you super familiar with the Hopiabara case? You know, it's pretty foggy. She took stuff out of a lab, right, and put it in water bottles? Yeah, she poisoned one of her coworkers water bottle. So that was how they, part of how they found that out. But yeah, she was a chemist. So she worked at a lab and she took pathogens and put them in her daughter's, um, I can't remember

the name of it, but it was like something basically put it in her lungs. Um, and then she also bled her daughter, um, through her PICC line and she falsified cystic fibrosis. And Hope had a big, like, eight-year-long cancer hoax as well that was like, once they discovered that, that's how they got the road in. So she's an interesting perpetrator because for me, actually, watching the interviews that Deanna Boyd, who's the reporter who broke the story in Fort Worth, did with her in prison was the closest I'm probably ever going to come to sort of getting any answers about what was going on with that person. I mean, it was very couched. And she said that she didn't remember doing these things.

She'd had a diabetic coma that made her forget a bunch of stuff conveniently right when Mike Weber was about to arrest her. So she said, you know, oh, I don't remember. Or they would confront her with a fact and she'd say, well, the doctors say I did it, so I must have done it. Sort of distancing herself from it. Is that something that you've seen with other perpetrators? I have, actually. And yes, I've had perpetrators say, well, I must have done it because there I am on the video doing it.

With that said, we don't really consider that a true acknowledgement. That is recognizing that it happened, but acknowledging is truly taking responsibility, truly recognizing that I've engaged in a behavior that is harmful and could have potentially killed my child. And just recognizing the magnitude of that. And that's actually what we're talking about and acknowledging. So yes, we had many of what you're talking about, of saying, I must have done it, or I don't remember, but I probably, you know, yes, yes. And what's your take on that at this point? You know, when we're watching these prison interviews with Hope, she's doing the time. It's not going to, nothing she's going to say in that interview is going to make her situation any

worse. And in fact, to my mind, it's a possibility of a redemptive moment, right? It's a possibility to publicly acknowledge what you've done and possibly build a bridge back towards a relationship with your children and with the rest of your family, which is what she was saying she wanted. She's saying she wanted all along, I want to be back with my family. I've lost everything. And so I wonder what you think about someone who's in that situation, what their motivations are for continuing to push it away like that. It's a great question because I don't, you're right. I, I, there's, there's no reason not to other than admitting it to herself. And I wonder, none of us could know,

but I wonder if that's part of it, if it's just very, very difficult to admit to herself that she's engaged in these behaviors, especially when you're presenting yourself as this caring, loving parent. And, you know, the opposite is true. You are harming your child. Very difficult to admit to it. I, you know, I've said before that it takes a lot of personal power to get to that place. Talking about prison, I've had a couple of the parents that I work with go to prison, and I felt that it was, believe it or not, a very useful experience because it was a space to spend quite a lot of time, you know, examining, looking at the behavior. They were able to get some good therapy in prison that helped them move forward.

So I'm hoping that the same can help or is available to other perpetrators in prison. Yeah, that would be ideal probably for the whole justice system, but that's a whole other ball of wax. Yeah, and I wonder, you know, as a sort of follow up to that question, what is the long term trajectory for a perpetrator like this. Eventually their children grow up, hopefully, and make it to adulthood and are no longer in their care. So what happens to someone like this after they're no longer the mother of children? Because that's the highest percentage of perpetrators that we see are the mothers of children. Exactly. And what I have seen is that several of the mothers that I'm aware of, especially if they are still in childbearing years, have gone on to have other children. Which is why trying to be able to intervene, trying to do treatment is so important. Trying to maintain contact with these families so that we can help them, you know, with future children. We've seen situations where

if they don't go on to have their own biological children, they do go on and remarry. And those may be families that also have children. And so as far as reunifying with their own children, their biological children that they have been removed from, we have seen this happen as well. And sometimes with not very great outcomes, children that then felt that they had to accept, again, accept the story that they had not been abused. And perhaps they knew better. Hard to know. And I've really been wanting to kind of ask all of our experts that we're talking to whether we should be looking at Munchausen by proxy perpetrators as criminals to be prosecuted or sick women who need help. And it sounds like you're saying both. So I'm guessing what sort of order should we put that in then maybe?

That's a great question because yes. So the diagnosis given to individuals that engage in munchausen by proxy child abuse is factitious disorder imposed on another. It's the diagnosis found in the diagnostic statistical manual, and it is an indication of a psychological disorder. With that said, it's a psychological disorder as well as recognizing that someone with this diagnosis has engaged in child abuse and a crime. As far as what order to put it in, I think that my experience is that both can happen simultaneously,

which is difficult. I think in, gosh, I think in all the cases I've worked with in which I've done treatment with perpetrators, there's been a legal case, a criminal case. So here you have an individual who either has to plead guilty or not guilty, which means if they're pleading guilty, then they're open to entering into treatment because they're acknowledging. If they're pleading not guilty, then the treatment really can't proceed. So the ones I've worked with have pleaded guilty, have acknowledged, have gone to prison, have done their time, have worked in therapy throughout the process, and have been able to, as I mentioned, some have been able to reunify with their families.

Yeah, I mean, it's, it's, I think that that reunification question feels especially tricky to me, just because I think that we can look at someone and see them in the full picture of their humanity and extend empathy towards them and also sometimes acknowledge that that person might not be capable of parenting, right? Exactly, exactly. And it is a rare parent that is able to do that work. Yeah. So what do you think can be done to better protect children from this kind of abuse? I think the main way that we can protect children from munchausen by proxy child abuse is to recognize it, is to recognize it exists, and to then know what to do, which is to report and to help Child Protective Services understand this form of abuse because it's still so misunderstood. It's frequently not recognized, and when it is,

it's misunderstood. So reporting, understanding, getting the information. I mentioned APSAC before, American Professional Society on the Abuse of Children. So APSAC.org. If you go to the website, you can download for free practice guidelines. And they're multidisciplinary. The audience is pediatricians, psychology, psychiatry, social work, judges, attorneys, all of us that are involved in these cases. So the best way to protect is to recognize and report. Yeah, we'll definitely include those in the show notes and everywhere when we're talking about this, because that's, I agree,

it's an amazing resource that you guys have all put together. And I think that anybody who's working with children should really understand this. It just amazes me how I still, just this week, you know, several cases have come across my desk and there's not been a report. Yeah. I mean, it's funny that you said earlier in the conversation, you mentioned, you know, when I was first working on this, there was just nothing. And I was like, as opposed to now where everyone's so well informed. You know, I mean, it still feels like, I mean, with all, you know, respect to all the work that you guys have done. And it's been really wonderful to connect with other people through this podcast. You know, it's just been quite an incredible experience. But obviously,

there needs to be more of that, too, because, you know, it just is, I think a lot of people still don't know what it is. I'm always shocked when I'm talking to someone who's, you know, a really educated person, and they're a lawyer, and they're this and that, and they've just never even heard of it. Not even, you know, and more people have heard of it now, obviously, than even a few years ago. I think that for all it's, for all the things that are not helpful about the Gypsy Road splintered and all the many media properties that's now expired, you know, all the things that that's inspired, there was some misinformation that went along with that as well, but at least people have heard of it and you're not, you know, but most of the time you are starting from scratch with people. Exactly. Well, when I started in 1989,

I think there was one book and I think there were maybe five articles. Wow. Yeah. So yeah, I would ask people in the audience and no hands would go up. You know, now most hands go up when I say, have you heard of? I'm always really fascinated to ask those of you that have chosen this as a professional direction. This is not an easy area to focus your entire, you know, your professional life on and can often come with quite a bit of blowback. And so I wonder for you, what is it about this issue that you find so compelling to have dedicated so much of your time to it? You know, it's a great question because I can't say I chose it. It's, I was in the field of child abuse, certainly, and actually family therapy. But since I had a case in 1989, and I saw the case, and then because

I had one case, I got referred to another case. And since I had two, you can imagine, right? And so, and it was hard to say no, because no one else had even had a case. And eventually, I think that's how a number of us have gotten to this place, actually. So, so, so it is hard for me now, we are actively recruiting individuals to, you know, to work in this field. It's difficult. You're right. There's a lot of, uh, there's a lot of reasons not to, um, it's tough. It's emotionally tough. It's professionally tough. Um, it can be legally tough. Uh, so it's a lot to take on. And yet when you come across these cases where, you you know that because of the work you did, a child's life was saved, that's huge. So how do sort of race and socioeconomic demographics play into this? Is this more of a white upper middle class in the United States disorder,

or is this across the board? Yes. Well, certainly what we've seen in the literature, cases have been reported across the globe, at least in 24 other countries besides the U.S. All SES, social economic status, backgrounds, certainly all races. It does seem like in the U.S. a number of cases that have kind of become very apparent in the media. There has been a high percentage of Caucasian mothers that we're seeing, but also I've certainly seen all races involved. Do you think, what do you think the reason for that is? Because we've definitely noticed that trend as well. Is that just because that's who the media will pay more attention to, or what's your take on that? You know, actually, I know of at least two

cases that are non-white that are pretty big media cases out there, but I have no idea why that it seems like a high percentage of the cases that really are high-profile media cases tend to be Caucasian cases. Interesting. So is there anything else before we sign off that you would want people to know about this issue? You know, the thing is you can probably tell that I push guidelines and reporting. Acknowledging reporting no matter what. That's the part that just kills me.