A Guide for Therapists: Perpetrators, Survivors, and Family Members

The effects of a Munchausen by Proxy case are typically far-reaching as they include years, sometimes decades-long deceptions that can involve dozens of people.

Munchausen by Proxy perpetrators deceive not only the medical professionals treating their children, but often their family members and friends, their spouse, their children’s educators, other caring professionals, and even strangers who may be pulled in by the story of a sick child. Though financial fraud is common, an MBP perpetrator is not primarily motivated by financial gain, but many times by the attention, sympathy, and admiration they receive for being the parent of a sick child. 

Treating Perpetrators

Many—but not all—perpetrators of Medical Child Abuse meet the diagnostic criteria for Factitious Disorder Imposed on Another. Intentional deception is a key component of FDIA, and is usually distinguishable from parents who are overmedicalizing their child because of parental anxiety or delusions that the child is truly ill. Perpetrators of this abuse are extremely challenging to treat.

• Many perpetrators who receive treatment do so because of a court order rather than choosing so voluntarily.
• Therapist should have access to an MBP expert for regular consultation during the course of treatment.
• It is important for therapists to work with CPS to establish a therapy agreement that includes boundaries around treatment, a clear plan, and safety protocols for the child.
• If a perpetrator continues to deny that the abuse took place—which the vast majority of them will do—treatment will be unsuccessful.
• The exceptional ability to successfully deceive others is a core aspect of the FDIA psychopathology. It is crucial to keep this fact in mind in order to effectively adapt assessment and treatment procedures.
• Therapists are advised to use the ACCEPTS model for treatment: ACknowledgement, Coping, Empathy, Parenting, Taking charge, and Support. Abusers are almost always a child’s mother and often have coexisting Cluster B personality disorders such as borderline, histrionic, or antisocial (sociopathic) disorders, or they have a mixture of problem personality traits.
• The abuse is conscious, planned, and carefully researched and executed. MBP abusers understand right from wrong and are aware of their actions.
• MBP is a high-shame behavior and has traits in common with addictions, eating disorders, impulse control disorders, and pedophilia, both in terms of the persistence of the behavior and the intentional efforts to conceal the disordered behavior.
• Many with FDIA have the ability to superficially appear “normal” if not exceptional as caregivers. Therefore, it is common that a basic psychiatric interview and/or psychological testing may suggest no psychopathology is present.

Treating Victims and Survivors

Because this form of abuse is severely under recognized, more studies are needed to understand the long-term impacts of Munchausen by Proxy and Medical Child Abuse. Most therapists will receive no training specific to help survivors of this abuse and should take the time to educate themselves. While many of the treatment paths will be similar to treating a survivor of any other form of child abuse and trauma, the general ignorance and confusion over Munchausen by Proxy can leave survivors feeling especially isolated.

We highly recommend reading the APSAC’s Advisor and checking out Dr. Marc Feldman’s website for more information.

Child Victims

• Victims will often maintain a positive view of the offending parent and may lie for and attempt to protect them by maintaining the falsehoods created by the offender.
• Victims may not know the reality of their health status and will likely need to be informed of their true health needs.
• Children can suffer permanent physical damage such as: blindness, hearing loss, altered gut function, brain damage, scaring, removal of organs, surgical alteration of anatomy, limps, etc.
• Victims may suffer from Shared Psychotic Disorder (also known as folie a deux) in which they truly believe they are as ill as the perpetrator claims.
• Victims can suffer severe psychological damage including significant confusion about their health and relationships, overly compliant or aggressive behaviors, adoption of self-falsification or somatizing behaviors, loss of positive self-image, post-traumatic stress disorder, and disordered eating.
• Treatment should focus on:
  • • Providing support
    • Managing trauma
    • Exploring story of illness and health
    • Teaching coping skills
    • Encouraging optimal independent functioning

Adult Survivors

Survivors of Medical Child Abuse face a difficult road given the often-lifelong nature of their abuse, as well as the stigma and taboo surrounding it. The revelations around the abuse frequently cause deep ruptures in families and even whole communities. If they choose to continue a relationship with the offending parent, good boundaries are of the utmost importance. If they choose to cut the parent out of their life, this decision would be supported as well.   (We don’t want to sound like we are pushing for this.)

Because of low public awareness of Munchausen by Proxy, it can be difficult for survivors to explain to friends and loved ones what they’ve been through. We encourage sharing this site to help those in their lives understand what they’ve been through. 

• MBP abuse is likely to deeply affect how survivors see their own health and how they feel about medical professionals: sometimes survivors will somatize or even find themselves engaging in Munchausen behaviors, while others will avoid medical care at all costs—even when desperately needed.
• It’s important that all medical professionals who are treating a survivor are aware of the history of abuse.
• A full accounting with the perpetrator is often not possible and survivors may cut off contact or will need to maintain extremely good boundaries with the parent in order to maintain their own wellbeing.
• Survivors often suffer from betrayal trauma and PTSD. Trauma-focused psychotherapies such as Cognitive Processing Therapy and EMDR may be helpful in recovery. 
• Feelings of self-blame, shame, and stigmatization are common.
• Support systems are crucial to recovery. Friends and family members who recognize and affirm a survivor’s experience are extremely important.
• Survivors often struggle with trusting others, having been betrayed by the person meant to protect them. Their relationships may suffer as a result. 

Treating Family Members and Others

The damage done to the immediate family of a Munchausen by Proxy perpetrator and her victim(s) is often profound. Non-offending spouses, grandparents, siblings, and cousins may find themselves waged in bitter battle with the perpetrating parent and cut off from the children they are attempting to protect. In addition to the personal drama inflicted by perpetrators, family members and friends may find themselves on the losing end of fraudulent fundraising activities for alleged medical expenses and having been the target of what is essentially a very lengthy con. This can cause trauma and great stress on those involved, especially if there is a long court case and/or custody battle.

• Non-perpetrating fathers in particular may struggle with intense feelings of guilt at not having recognized the abuse sooner, as well as deep trauma over the betrayal by their spouse. Because many times the family court system is not equipped to recognize this form of abuse, it’s not uncommon for the non-offending parent to lose custody to the perpetrator.
• Family members frequently suffer from PTSD and betrayal trauma as well as the loss of the relationship not only with the children, but with the perpetrator herself who was a beloved family member.
• Having been victims of a long-term, extremely damaging deception, those close to the perpetrator may struggle with trusting others.
• Because of the low-level of public awareness, secondary victims of a perpetrator may feel extremely isolated in what they are going through.
• Perpetrators are often litigious and because of their desire for attention and may actively try to disparage those who challenge them.
• Family members often struggle with intense feelings of helplessness and fear over what may happen to the children in the—unfortunately common—event that they’re returned to the perpetrators care.

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