IPT Book Reviews

Title: Hurting for Love: Munchausen by Proxy Syndrome  Positive Review
Authors: Herbert Schreier and Judith Libow
Publisher: The Guilford Press 1993

The Guilford Press
72 Spring Street
New York, NY 10012
(212) 431-9800
$26.96 (c); $13.95 (p)
 

Description:

Hurting for Love is the first book ever about a complex form of child abuse called Munchausen syndrome by proxy; heretofore discussed primarily in medical journals.  The authors use a precise, narrow definition of Munchausen by proxy syndrome as they call it, abbreviated (MBPS).  The parents they describe, usually mothers, masquerade as perfect caretakers while secretly it is the parent causing the child's illness.  The child, often an infant, is portrayed as first dehumanized by the mother, then used by her as a fetish-like object to sustain a special relationship with the child's doctor.  According to the authors, harm to the child is not an end in itself but a byproduct of the mother's efforts to engage a powerful, often male authority figure.

The book opens with a humanistic forward by Dr. Roy Meadow, the British pediatrician who first described the syndrome as we know it today.  The wealth of information that follows is presented in an easy-to-read style.  Respectively, the authors are Chief of Psychiatry and Director of Training for the Department of Psychiatry, at Children's Hospital in Oakland, California.  They present material drawn from their own clinical, consultation, and research experience, as well as from that of other professionals.  A unique feature of the book is the number of direct and sometimes extensive quotes from people who have been involved with these cases in a variety of roles.

The first of the book's three parts elaborates on commonly accepted features of the syndrome.  The mother/perpetrator often has an unusual grasp of medical terminology and may be in a medical or quasi-medical field.  Because these mothers blend in well with the medical environment, they generally do not seem unusual to doctors, staff, or neighbors, although sometimes they claim that dramatic and unverified incidents such as fires and burglaries have happened to their families while they were in the hospital.  They are likely to be married but to men who are emotionally distant or physically absent much of the time.  The husbands are not involved with the children's medical problems and often react with disbelief when presented with clear evidence of what their wives have been doing.  Occasionally, a father has been found to collude with the mother in the MBPS abuse or to be the lone MBPS perpetrator.

Co-morbidity in siblings is discussed.  It appears that Munchausen by proxy parents may carry out this form of abuse with more than one child, simultaneously or serially.  This finding has important implications for case management and disposition.  It is not uncommon to find that a sibling of the identified MBPS child has died of mysterious causes.  It is now believed that some child deaths previously attributed to Sudden Infant Death Syndrome (SIDS) were the result of suffocation by an MBPS parent.

In section two, the authors elaborate on what they believe causes the syndrome, exploring two important themes: why 95% of MBPS perpetrators are women and why the pediatric health care system is the chosen arena for acting out this type of deception.  Women are traditionally socialized to empathize with and care for others rather than to articulate their own needs for recognition, power, and nurturance.  Their socially acceptable role is codified in the health care delivery system where women carry out many of the essential, supportive roles but are granted little status as medical caregivers.  The MBPS mother senses and actually helps create the pediatrician's point of vulnerability, which is when things are not going well clinically.  According to the authors, she manipulates the pediatrician's expectations of himself as a competent caregiver, causing him to feel that if he cared enough he would be able to cure this child.  Reluctant to share his feeling of inadequacy with others who might help him gain perspective, the pediatrician tries harder to work with the mother in discovering what is wrong with her child.

The third section is devoted to the systematic diagnosis and management of MBPS abuse.  State-of-the-art guidelines are offered for 1) suspecting and identifying MBPS, 2) verifying MBPS, 3) confronting an MBPS parent, 4) long-term management of MBPS parents and children, and 5) assessing if and when reunification of parent and child is appropriate.  Medical documentation and careful review of medical records are of utmost importance since circumstantial evidence may be the strongest evidence linking the mother to fabricating or inducing illness in her child.  Legal and ethical issues are discussed with respect to covert video surveillance of the child in hospital in an effort to document suspicions that the mother is smothering her child.  Psychological test data on 12 MBPS mothers is presented.  The appeal of ordering the mother into therapy as a condition of reunification is viewed with extreme caution.  The few reports of "successful" treatment of the mother rely on questionable criteria for success and an absence of long-term follow-up.

In the epilogue, the authors express their ambivalence about the fact that dissemination of information about MBPS, especially sensational coverage by the media, will undoubtedly lead to unjustified suspicion in some cases, causing anguish to families attempting to care for genuinely sick children.
 

Discussion:

Hurting for Love is an important book which will provide practical guidance to physicians, hospitals, child protective agencies, and the courts, as well as raise the consciousness of mandated reporters and the general public.  It presents MBPS abuse in a neat, comprehensive, total package which is both its strength and its weakness.

Schreier and Libow's over-commitment to their hypothesis that the mother's primary motivation is to maintain a special relationship with the child's doctor has the effect of dogma.  While the hypothesis is well developed and intrinsically interesting, it fails to integrate conflicting material and thereby stultifies further scientific inquiry.  The authors relegate to a footnote Dr. Meadow's finding from interviews with MBPS mothers that they were not seeking the attention from a particular physician but were looking for a way to leave home (presumably by joining the ready-made world of hospital culture).  Nor does the book account for the fact that several MBPS mothers admitted to Meadow that they were trying to kill their children.

Another of the book's overvalued ideas is that MBPS is so unique that it is qualitatively different from adult Munchausen syndrome.  In the same vein, MBPS is presented as different from other forms of child abuse in that the abusive parents appear to the world to be deeply concerned and caring.  The importance of these differences is not that MBPS is special and unique but that it can teach us things about the two major classes to which it belongs: factitious disorders and child abuse.

The authors are clearly aware that MBPS parents, once discovered, can transfer their attention-seeking efforts from the medical establishment to therapists, social workers, and the child protective establishment.  What they fail to comprehend is that some parents do more than transfer the MBPS behavior to this arena.  Some parents use the child protective establishment as their primary arena for this type of emotional abuse, presenting the child fictitiously in the victim role.  In my work, I define this as a contemporary manifestation of MBPS because it has developed in tandem with the proliferation of social services directed at managing the problem of child abuse.  Schreier and Libow mention my work in passing but consistent with their tendency to downplay data that does not fit in with their view, they fail to explain or integrate it.  Meadow recently reported on 14 cases of dual factitious disorder by proxy in which mothers were simultaneously presenting their children to the child abuse establishment in the victim role and to the medical establishment in the patient role.  For 11 of these children, it was the discovery that the abuse allegations were false that led to the discovery that the children were also incurring factitious illnesses.

Schreier and Libow's analysis of the MBPS mother/pediatrician relationship has important ramifications for the way in which physicians are trained.  Current training socializes physicians to maintain the appearance of being more knowledgeable and more powerful than they really are.  When a physician with this mindset comes in contact with a mother who is determined to appear more perfect than she really is, a dangerous form of child abuse can result.  The training of therapists and child protective workers should be subjected to similar scrutiny.

Reviewed by Deirdre Conway Rand, Mann Psychological Services, Mill Valley, California.

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