||Hurting for Love: Munchausen by Proxy Syndrome
||Herbert Schreier and Judith Libow
||The Guilford Press © 1993
The Guilford Press
72 Spring Street
New York, NY 10012
$26.96 (c); $13.95 (p)
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
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
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.
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
Reviewed by Deirdre Conway Rand, Mann Psychological
Services, Mill Valley, California.