CLEARER THINKING

with Spencer Greenberg
the podcast about ideas that matter

Episode 176: Mothers who harm their children for attention (with Andrea Dunlop)

September 21, 2023

What is Munchausen syndrome? How does Munchausen syndrome differ from malingering? Does Munchausen usually correlate with lying or exaggerating in other contexts (i.e., pathological lying)? What is "Munchausen by Proxy" (AKA "factitious disorder imposed on another", or FDIA)? Why are women the offenders in the overwhelming majority of cases? What are some consistent patterns of behavior exhibited by people with MBP? What is a "reality distortion field"? How do people with MBP tend to deflect requests for facts? Do such people believe their own stories? How does MBP relate to sociopathy or psychopathy? How common is MBP?

Andrea Dunlop is an author and podcaster based out of Seattle, WA with two decades of experience in book publishing. She is the author of four novels: Losing the Light (February 2016; Atria), She Regrets Nothing (February 2018; Atria), We Came Here to Forget (July 2019; Atria), and Women Are the Fiercest Creatures (March 2023; Zibby Books). Andrea is host and creator of the popular true crime investigative podcast about Munchausen by Proxy called Nobody Should Believe Me, which was a New & Noteworthy pick for Apple's Dark Side collection. Her non-fiction book on the same topic is forthcoming from St. Martin's Press. She is a member of the American Professional Society on the Abuse of Children's Munchausen by Proxy Committee and is the founder of Munchausen Support, which is dedicated to providing resources for frontline professionals, families, and survivors dealing with MBP. Learn more about her on her website, andreadunlop.net.

SPENCER: Andrea, welcome.

ANDREA: Thank you so much for having me, Spencer.

SPENCER: One thing that I spent a lot of my time doing is trying to understand human psychology better. I think a really interesting test case for human psychology is to look at extremes, where people have very unusual behaviors. And the reason I wanted to invite you on today is to talk about one of the strangest behaviors that I've ever heard of happening among humans. And I know you personally have had an interesting experience with this. So, why don't we start talking about Munchausen syndrome? And from there we'll go into the actual subject of this episode, which is Munchausen by Proxy.

ANDREA: Sure. It is definitely at the extreme of human behavior; that's an apt description. I'm just gonna throw out a couple of more official terms just because I think that's important. However, I do use Munchausen by Proxy all the time. Munchausen syndrome, also called factitious disorder, is a condition in which someone exaggerates, invents or inflicts illness on themselves for the purposes of sympathy and attention. It is a strange behavior, I think, that I always like to sort of bring down to earth by telling people that it is sort of a very extreme version of a behavior that a lot of us can probably relate with, which is that notion of having people take care of you and feel like you are getting people's attention, and people are looking after you. And that thing that we all do — at least to some degree when we're kids — of pretending we're a little bit sicker than we are so that we can stay home from school, and maybe our mom's going to give us some extra love. I always like to frame it like that, so it doesn't sound quite (I guess) off the spectrum bizarre.

SPENCER: Probably many people have that experience of kind of exaggerating how sick they are because it makes people treat them in a certain way or be more sympathetic or so on, especially as children. Where it starts to get, I think, especially peculiar is when it's a completely fictitious syndrome that they're suffering from that they're just using for attention. So to be Munchausen syndrome, does it have to be completely made up? Or could it just be an exaggeration?

ANDREA: Exaggeration counts. I think that one of the very common misconceptions about both Munchausen and Munchausen by Proxy is that if there is the existence of some underlying condition, then that sort of "proves that that person is not committing that act." It's obviously much more serious in the case of Munchausen by Proxy because it is child abuse. But even Munchausen, and again a lot of the cases, especially the ones that are making headlines, will be things like these very serious long term fake cancer stories that turned out not to be true. But there also is a version of this behavior that is someone who does have some kind of chronic condition that really amplifies and exaggerates their symptoms, again, in order for an intrinsic reward. So another thing to always have folks understand is that it is separate from another disorder called malingering, which is when you do some of those same behaviors — exaggerating, inducing or inventing an illness in yourself — but it's for an external reward. So, to get out of school, for example — so I guess all kids engage in some malingering is what I'm saying — to get out of military service, to get out of work, or just doing a fraudulent GoFundMe page. Now, it can get confusing, because in these larger cases that go on for years and years, there usually are things like some fraudulent fundraising and some other sort of external rewards. But the difference being that they would do it in the absence of those external rewards. So really, that intrinsic reward of getting attention and sympathy is thought to be the main thing.

SPENCER: And certainly in scenarios where there's a draft, some people are going to pretend to be sick to avoid the draft, whether they're afraid of war, or they think it's an unjust war, or they don't want to go kill people. I think that happens a lot. And we can all understand in that kind of scenario, that's going to happen. But that's really different than doing it for attention or to get people to treat you differently.

ANDREA: Right, correct. And I think that's why it's so baffling to people is because I think it's much easier to explain, to your point, that if they're getting out of going to war or if they did it so that they could fraudulently raise a million dollars for cancer treatment they didn't need and then used it to go on a trip around the world or buy a house or something. Those are actually much more easy to understand then someone that would engage in that behavior in a long term way that really hurts and exploits other people for the purposes of getting their emotional needs met. But what I've come to understand in many years of thinking about this and engaging with this is that actually getting our emotional needs met is one of the most powerful drivers of human behaviors. That actually, to feel loved is something that people will do almost anything for.

SPENCER: Yeah, that's a really interesting point, where we can maybe relate on some level more with someone who might pretend to be sick or hurt themselves to avoid some calamity or avoid something they really, really don't want to do. But then when you think about love and acceptance and so on, well, aren't those actually incredibly important things to us? And so, is it that shocking that someone would engage in this behavior for those things? But I think it is simply less relatable. Even though we all want those things, we all want love and acceptance, maybe most people have an intuition that getting it through deception isn't the real thing. Like, if someone loves you only because you trick them, or if someone is showing you sympathy because you're tricking them, that it somehow degrades it.

ANDREA: Right. I think for most of us, we would feel such discomfort with lying, especially to our friends and family and those closest to us. You can understand from a distance what the reward is. I think we can all probably think of times in our life when we were going through something really hard, like an illness, or even just...I've had two babies in the last five years, and when you have a new baby, people (hopefully) in your life really show up for you, and they go out of their way, and they take time out of their schedule to make your meals and there's all this. And that's a nice feeling, right? It's nice to have people show up for you in that way when you need them. Most of us wouldn't go so far as fraudulently creating a need to get that. And so I think to your point, if you were being deceptive about it, that would sort of negate the reward for many of us. But I think for folks that have this, it's like deception is an integral part of it. The other thing that I've seen with looking at a lot of these cases that involve both Munchausen and Munchausen by Proxy is that it's never isolated to health things. It's never just that they're lying about their health. There is a massive pattern of lying about all kinds of other things: financial fraud, lying at work, infidelity in their relationships. You see this huge pattern of really pathological lying that goes back even before someone can identify when they started lying about their health issues. So it is an overall state of mind and it's connected to a lot of other personality disorders that are difficult to deal with on their own. So those Cluster B personality disorders — that I feel people are a lot more familiar with these days because of TikTokand podcasts, etc. — narcissistic personality disorder, borderline personality disorder, histrionic personality disorder. Again, those things on their own, without the factitious disorders, are hard enough to deal with. So it is sort of an overall question of someone that is really using a different playbook than the rest of us, I would say.

SPENCER: So let's transition to talking about the subject of this podcast, which is going to be Munchausen by Proxy. Could you tell us what that is and how that differs from Munchausen? And then we'll get into your story and talk about how you came to be so interested in this.

ANDREA: I like to describe Munchausen by Proxy as the sort of colloquial term that we use to describe two separate but intertwined things. One of which is the underlying mental disorder that someone who does this has, which is "factitious disorder imposed on another." So again, that's when someone is exaggerating, inducing, or inventing illness, this time in someone they're caring for; so in someone else, not themselves. So, almost always the mother of a child for the purposes of sympathy and attention. And then the other thing that we use Munchausen by Proxy to describe is the act of medical child abuse, which is when someone is using deception to exaggerate, induce, invent illness and harming a child with that. So the thing that really distinguishes Munchausen by Proxy and makes it a much bigger concern from a community standpoint. not that Munchausen behavior cannot also be devastating to people involved. But obviously, whenever you're talking about harming a child, that's a very serious thing. And in medical child abuse, there is a higher death rate than any other form of child abuse; it's thought to be around 6-9%.

SPENCER: Oh, wow. So in 6-9% of the time of these cases, the child actually dies from it. Just to be clear here, to the listener, we're not just talking about a parent telling their friends that their child is sick. We're often talking about much more extreme behaviors. Do you want to give some examples of the kinds of behaviors that might be typical?

ANDREA: To be clear, there can be a wide range of behavior that falls under this umbrella, that goes along the spectrum. A friend of mine — who has appeared on my show, "Nobody Should Believe Me," which is an investigative true crime podcast about Munchausen by Proxy cases — Dr. Mark Feldman, one of the foremost experts in the world on factitious disorders, actually coined something called "Munchausen by Internet" which is when people do these same behaviors, but they really keep them to the online sphere. So it's when people are either inventing their own illnesses, or there's been cases where people have invented an entire family with fake children who are suffering from cancer, and they find other people's photos of children who are actually in the hospital and et cetera, and sort of build out these entire fake lives. It's a similar behavior in that the reward that they're getting out of that is, again, attention, sympathy. Now, for most of us, coming up with an entire fake identity to get those things would completely negate the benefit of those things. But that's why it's a compulsive behavior. I think what's interesting about how this plays out online is that, of course, there are a lot of people who have real children who also sort of amplify this behavior online. And every expert I've spoken to really thinks that the presence of both the accessibility of any information about any diagnosis or disorder you could possibly hope to research is a few clicks away. So that makes it much easier to commit. And then also the resources for getting attention, because of social media and online forums, etc., have become infinite. So those things have collided to make this problem a lot worse; it used to be a lot harder to pull off. We talked about a number of different cases on the show. And I always want to preface this by saying that just because these issues show up in a lot of Munchausen by Proxy cases does not mean that we should look upon parents who have children who have actual issues with any additional suspicion. It's not a causal relationship that way, but we do see a lot of premature birth — that's something I've seen in almost every case — there are a lot of things that follow that sort of feeding issue, so things where you'll see babies' diagnosis: failure to thrive, which is a catch all term for babies who are not developing or gaining weight or growing the way that they should. And then you will have parents take progressively serious medical interventions to deal with the failure to thrive. So, a lot of times you see, first, starting with a nasal gastric feeding tube (which is the one that goes in through the nose) and then moving on to a surgically implanted feeding tube. Again, those feeding tubes are something I've seen in almost every case. And of course, there are a lot of children who have those legitimate issues. But the difference here being that the parent is lying about the reason that the child is not gaining weight. The reason the child is not gaining weight, in these cases, is because the parent isn't actually feeding them, but they are telling the doctor that they are. And so again, that intentional deception is always a hallmark of these cases. It is not kids with complex medical issues. And it's not even parents who are overly anxious or even suffering from delusions. Sometimes people will over medicalize their children, or inappropriately medicalize their children, because they actually think they're sick. This is very different. These parents know their children are not sick, and they're doing this behavior in a very purposeful and premeditated way. I've seen a lot of things that sort of fit into these patterns. Another thing that comes up a lot is breathing issues. So things around asthma, a lot of seizures that no one else ever sees. So really, anything that is not going to show up on a simple blood test or X ray, or is something where the test could be messed with. I think what has really been illuminated for me going through so many of these cases is just how much of what a doctor does — and especially in pediatrics, especially if you have a very young child who is not verbal yet — you are really completely dependent on the parents telling you a history and the parent giving you a record of their symptoms. I have two little kids, so I look at what those doctor visits look like. They're usually short, and they're usually just asking me, "Hey, what's going on with your baby?" And their job is completely dependent on telling me the truth. And if I don't tell them the truth, they're going to come to the wrong diagnosis. So that is what happens in these cases.

SPENCER: I just want to emphasize just the level of disturbing behavior that's occurring here, because, often, we're talking about a baby or young child. A parent is going to the doctor saying that, "My child is having all these problems," when in fact these problems are being induced by the parent, and then they're knowingly getting unnecessary medical procedures to treat this non-existent problem that they themselves created.

ANDREA: Correct. Back to your question about, what if there is some underlying problem. There are a lot of cases in the news that have been depicted in documentaries. And the other thing about "false accusations" or parents saying that they have been falsely accused, and something that sometimes parents will say is, "Well, they really did have this thing. They really did have this underlying issue." Okay, they may have an underlying issue. But if you look at the way that that underlying issue has played out for that child — for instance, maybe they were born premature. Now, the prematurity thing is really complex, because we know from some of the peer reviewed literature on this, that there are offenders who have, again, it's one of those things that almost every case I've looked at the baby is born premature. And then you also see when there's more than one child, the babies are born increasingly premature. And so — there are offenders who have said that they caused that premature birth so that they could start that pattern of getting that medical attention, and that they felt that they were getting their emotional needs met by being treated like a high-risk pregnancy. And so it begins before the child is even born. But nonetheless, they can say, "Oh, well, this child had all these issues because they were premature." But then you look at most premature babies, yeah, they have some eating issues right in the beginning, but they usually resolve. They're not escalating to this mess by the time they're three, four or five years old. So again, it's just always looking for that intentional deception. And it is really disturbing. And I think that is what keeps people from looking at it. I think having been through an investigation, my son (not for me, but within my family), I know how hard it is to wrap your head around the fact that someone could do this. And especially the idea that many, many of these moms — and I say moms, because about 98% of known cases are mothers; it's a very female crime — a lot of these moms don't look abnormal. They don't seem abnormal. There's nothing off putting about the way they are. They just seem like really nice, normal loving moms. And I think to be able to look at someone like that, and also hold in your mind that they could be capable of doing the most depraved thing you can imagine, is really hard for people. And I understand why that's so hard for people.

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SPENCER: So let's get into your personal story. Do you want to go back to the beginning and tell us the progression that you experienced?

ANDREA: Sure. In the first season of my podcast, I talked a little bit about my background with my older sister, and I'm talking about it more directly in this season that is airing right now–season two. (I don't know when this will be coming out; that episode may have aired already.) So, I have an older sister who has been investigated for medical child abuse on two occasions: once for her older son and once for her younger daughter. The second investigation involved a two-year police investigation, as well as the CPS investigation that did escalate to a dependency case, i.e. the state made a motion to take her children away. That was denied by a family court judge. There are lots and lots of issues with the way that case played out. I believe the evidence against her was very strong. What I've been able to find in the public record is extremely worrying. Again, I talked through that in the second season of my show. We have been estranged for about 12 years. And my history with her is: she had a lot of these Munchausen behaviors that we talked about at the top of the show that predated her having children. It was kind of a situation where there was just always something with her health. And there's a lot of things, like anybody involved in these cases, one of the profoundly destabilizing things about having someone in your life like this and someone who really deceives you in major ways she did, is that you look back on a lot of your life and you're not totally sure what was real and what wasn't. So there are many things that I'll never know, presumably because I don't think she's going to give me access to her medical records. And without that, I have no way of knowing. But there were a couple of incidents that we knew for sure she was lying. One of which was that she said, in high school, she was losing her hair. She said she had alopecia. She had this bald spot on her head. My mother took her to the dermatologist and the dermatologist told her actually she's shaving her hair off; so she's doing it intentionally. That was obviously an alarming thing. And it happened when we were both teenage girls. And I think at the time, my mom tried to get her into some therapy, but not much you can do when someone's (I believe she was) 17 if they don't want to go into therapy. And so I think maybe we just filed it under "teenage girls do strange things sometimes," I can say, having been one.

SPENCER: That case is really interesting because leaving a bald spot in your head, you might think as a teenage girl, that would be embarrassing. It's a sort of thing where you think that you would want to try to fit in in school and look as normal as possible. So I'm wondering if you have any insight there of what she was actually seeking?

ANDREA: Yeah, that's a great point. And I think that part of why it's so hard to understand this behavior, and part of why it masquerades for so long, part of why it doesn't get detected earlier, if people don't know what they're looking at — and certainly, my parents had not heard of Munchausen syndrome when they were teenagers — is because it seems so "Why would you do that to yourself?" That's every girl's nightmare. To have something terrible happen to their hair is a catastrophe as a teenage girl. And that's not to say anything silly about teenage girls. It's just that that's where you're at. But it was something that got her a lot of attention, because people noticed it, and said, "Oh, my gosh, what's happening with your hair?" And now for me, as a teenager, I wouldn't have wanted people to ask me that question, feel sorry for me. But something that I understand about people that battle with Munchausen syndrome is that, that is how they are able to feel loved: by people expressing that concern and by people being worried about them. And it's both understandable on one level and then baffling on another level, because most of us just wouldn't want attention for something like that.

SPENCER: It reminds me a little bit of, in high school, you saw some students that seemed indifferent whether they got positive attention or negative attention. They just wanted attention, whether that was from acting out or from being praised. And it kind of reminds me of that, where attention is good, full stop.

ANDREA: I think that's true. The other thing that I thought about was that I'm very lucky in that my family has good bone density; I've never broken a bone. But remember, when you were kids, if a kid got a broken arm, and they had a cast, it was kind of a cool thing. It was like, "Oh, man, he has a cast," everyone's gonna sign it. You do get attention. And I think there is a sense that even attention for something — and that's not exactly negative attention, that's sympathy — but I think that there's something there that we can understand a little bit. I, of course, wouldn't purposefully break my arm or pretend to have a broken arm to get that sympathy, but maybe the cute guy or girl in class notices that you have a broken arm and wants to sign your cast. There's something there that I think a lot of us can relate to, just not the degree and not the deceptive angle.

SPENCER: A friend of mine in high school asked this guy to smash a baseball on her knee to try to induce an injury so she could get out of the gym. But I think that was more because she hated gym class so much, which is rather disturbing, but yeah.

ANDREA: That is a pretty long way to go to get out of gym class. But that's just that low grade malingering that a lot of kids engage in.

SPENCER: High school kids are not always making the best life decisions. So, what was the next sign that you didn't realize, but in retrospect, you think was connected?

ANDREA: Definitely the next really big thing with health stuff was that she had, when we were in our 20s, a pregnancy. She was with a boyfriend. I believe they were engaged at the time. But she said she was pregnant with twins, and that she lost that pregnancy at about six months in, which is an extremely devastating time to lose a pregnancy. That is obviously very far along in a pregnancy. We were at my parents'; they were both out of town. She called us and she told us this whole series of events, and she was going to the hospital and they were trying to save the babies and they couldn't save the babies and then it all came unraveled over the next several weeks. And we eventually surmised that she was probably never pregnant at all. And to say that was disorienting is a massive understatement. She looked pregnant, we had a baby shower, they had names, I'd seen ultrasound pictures. It was very, very elaborate. So that was obviously a huge turning point in understanding what she was capable of lying about.

SPENCER: I imagine that it's incredibly hard to come to the conclusion that your sister is lying about losing a pregnancy. There must be so much psychological momentum towards believing her in that case. So I'm wondering, how did you come to believe that she was lying? And what was that like for you as her sister?

ANDREA: Our capacity to believe, especially the people that we love, really will make us look past a lot of things. I think sometimes people can stand outside these situations and think, "Well, how could you not know something was up?" And it's not even that we didn't know. It's that when you really, really don't want to see it, and you really, really don't want to believe it, it takes a lot. So with that situation, I was living in New York City at the time. So I was back home, and I got a call from my father. I can't remember exactly what he said; it's a long time ago, but just basically, "Something's not adding up about what your sister is telling us about losing this pregnancy." I called her best friend, who I had also grown up with and was very close to, and asked her what her take on things was. And what we quickly realized was that she had told everyone a different version of the story. So in the story I heard, her best friend had taken her to the hospital. In the story she told her best friend, her fiance had made it home in time. And the story she told her fiance, who we came to find out was not her fiance anymore, was that a different friend had taken her. So it became really clear that something was not adding up. And then she went through this pattern, which I've now recognized is part of the pattern of these behaviors. It's this sort of deny, justify, minimize, blame. So she did exactly that. Whenever we tried to confront her (I'm not going to overstate my attempts to confront her), it's very hard. It's very hard to sit down and say to someone, "You've lied about this huge thing. How could you do it?" But she cried. And she first kind of tried to say that she had lost the pregnancy, but it had been much earlier than she said, and then she sort of changed that story. And then eventually, she just blamed her (by then) ex fiance, "Oh, he had left me, I was so ashamed." And because I wanted it to somehow be his fault — makes no logical sense, it was not his fault; this poor man — but I was like, "Yeah, it's his fault." You get on board, because I wanted to believe anything. But my sister had done this in a premeditated, purposeful way, and let us all believe, let me believe, that I was going to be an auntie, let me get attached to mythical babies that did not exist, and then let me experience a death (two deaths), and grieve over that situation. And for it all to have been a lie is just a horrible thing to sit with. And so, I think the way I dealt with it at the time was I just sort of didn't. I sort of came up with this other explanation: it was the breakup, and she has just always been a little troubled." And I watch other people do these in these cases when they're being confronted with really hard evidence. And I watch people sort of do backflips to convince themselves that it's not what it is. And I think that there's a point where that's no longer acceptable to do, especially if a child is in danger. But I also understand what they're doing.

SPENCER: It's like the reality of what your sister did, it seems, was so unbelievable and so shocking, that your brain is just willing to latch on to any bizarre explanation of it that doesn't involve, "Wow, she actually did that thing."

ANDREA: Yeah, exactly.

SPENCER: Did she ultimately admit to you that she had made it up?

ANDREA: No. There was a point at which it was no longer feasible to say that it was all true, because it was just so obvious that it wasn't. But again, it's one of the most crazy making things about dealing with someone like this and something that I have now seen as a pattern over the last two seasons of the podcast. I've gotten to interview lots of friends and family members and doctors who've dealt with people who have these same behavior patterns and it's very much a shared experience. Especially in season one, I interviewed Hope Ybarra siblings, and we just sort of talked about, like, you can just sort of never pin them down. It's like they sort of have an answer for everything. And it's never just, "Yes, I did that. That was hurtful. I'm so sorry." It's never that. It's always, "Well, I did it because of this." And tears. Just crying and back to evoking sympathy, where you just now somehow feel like you're being cruel by pressing the issue. It's just they're very, very adept at playing the victim and making any situation. Even if they are the person who is very much culpable for causing other people pain, they still somehow are able to make themselves the victim. And it's really hard to be a person who is not playing by that playbook. Having sort of the more standard emotional reactions to things, it's very hard to stay on solid ground at all. I always felt like, with my sister, there was a reality distortion field around her. And when I was talking to her, I couldn't hang on to the truth.

SPENCER: That's so interesting, because we see this idea of reality distortion field from other people as well. People often talk about entrepreneurs as having a reality distortion field. When they're pitching to you, you can get persuaded that what they're thinking is gonna be the next big thing. And then you don't see them for a week, and you're like, "What were they talking about? It's such a stupid idea." But somehow it seems so compelling. So I just think this idea of reality distortions is so fascinatingly important. And of course, cult leaders have this too, right? A cult leader kind of distorts the reality of the people around them and makes them think that all kinds of wacky things are true. And they really have trouble seeing past that. But this seems like a sort of a very particular type of reality distortion field. So I'm wondering, let's say you tried to pin someone like this down by just saying, "Okay, well give me the facts. When did you first find out you're pregnant? Okay, can you show me the hospital records?" etc. How might they respond to that to deflect so that you can't actually investigate it?

ANDREA: Well, I'll tell you exactly because I have a couple of instances. One of the things that came up as I was doing this digging about my sister's case and what was in the public record, some of what was in the public record, to my surprise, was a bunch of emails between her and her husband and my father from around the first case. So 12 years ago. In the first case against my sister, there was an investigation by CPS (not by the police), my parents and I had really deep concerns because my sister was telling us again, things about her son's health that we're not adding up. And of course, we had this backstory of her doing all these strange things with her own health. And after the CPS case was dismissed, there was this time when my dad was speaking to the two of them again. And he kept asking, kept saying, "I want reassurance that you're saying there's nothing to worry about. You're saying this is all a mistake, that she was never lying about his health, about her son's health, I want to see the medical records." And they kept saying, "No, that's not appropriate. You shouldn't be asking that. This is the wrong time for that." It's just sort of these evasive maneuvers. And so I think that is sort of what you deal with. And there was this tone in that conversation of, "No, you can't see that, and how dare you ask." And that is sort of where she was always coming from. Whenever I tried to pin her down for something, it was like, "How could you ask me that? How could you think that I would do that?" The final conversation that I had with her, that may very well be the final conversation I have with her in my life, was during the first investigation. It's probably the only time I ever really confronted her really directly about the fake pregnancy. I told her, "I love you. But I really think you need help. I'm really worried about my nephew. And I'm not basically willing to say that I don't think there's anything wrong here." She was very indignant, and she said, "How could you possibly think I would be capable of this?" And I said, "Well, you lied to me about an entire pregnancy." And her response to that was, "I don't know why you're bringing that up now." I was like, "Well, it's germane." But that is the exact sort of way of dealing with it. It's that: deny, justify, minimize, blame. And so that's just the pattern I've seen her play out again and again and again. And even when I sat down and interviewed Hope Ybarra, someone who spent 10 years in jail for it, she said that she had this diabetic coma — spoiler alert, didn't happen — and doesn't remember anything. So she'll say, "Well, yeah, I know I did those things, because the doctor said I did them. But I don't know why I did them, because I don't remember doing them." And so it's just like you can never pin them down. That's an absolute hallmark of the personality.

SPENCER: That mechanism for getting out of the questions, does it make you feel guilty when they do that? Is that what they're trying to evoke so that you change the topic?

ANDREA: For me, that is certainly how I always felt. I always felt like, somehow when I was trying to hold her accountable, I was bullying her or picking on her. And certainly that's the language her husband has used. He wrote a bunch of social media posts about me and the show when the show first came out, and that was the language he used. He kept saying, "This person is just bullying her sister."

SPENCER: Oh, because at that time, he was not on your side.

ANDREA: Oh, he's still not. He still just says that I'm a liar and there's nothing to all of this and etc, etc. He said, "Oh, you're bullying her." And the language that she's used about me and about my parents is that we're toxic. It's sort of like, yeah, you're framed as picking on the person and being cruel that you would even accuse them of doing a thing, even if you have very strong evidence that they are doing that thing or have done that thing. It sort of doesn't matter. I It's really illuminated for me how there's reality, and there are facts, and there's evidence, and then there's sort of everyone's story about what happened. And those two things do not necessarily have any relationship to each other.

SPENCER: Hmm. It sounds almost like a form of weaponized guilt.

ANDREA: Oh, yes, yes.

SPENCER: But I think the story point is also a really interesting one, where some people are so focused on a story, that it's the story that matters, not the reality. There's a natural spectrum of that, where in different people's lives, some people are more story type people, and some people are more fact based type people. But this is almost taken to an extreme where I actually wonder whether people with this disorder believe their own stories a lot of the time. And so I'm curious about that. And maybe it's hard to know, but do you think that they sometimes actually believe what they're saying in the moment?

ANDREA: That was one of my biggest questions going into this. To your point about being story people or fact people, I'm a novelist. I am a story person. But that was one of my biggest questions. It seemed like, when I was talking to my sister, that she wholeheartedly believed what she was saying. And so I wondered, is there some aspect of delusions? Has she convinced herself that things happen the way that they did? And I spoke to a wonderful colleague of mine on the show, Dr. Mary Sanders, who has done a lot of work, particularly on treatment for Munchausen by Proxy perpetrators and has worked with a lot of perpetrators. And in talking to them about their experiences, the way she described it was that they become very adept at compartmentalization and justification. So it's a conscious act — they understand their child's not sick or as sick as they're saying, or whatever the case may be — but they are able to sort of put that away in their brain and give themselves over to the story, to the fiction. And they're also able to find ways to justify their behavior. So they can say, "Well, yes, I'm keeping my child in the hospital for nine months out of the year." But look, they're getting to go on and make a wish trip to Disneyland, or they're getting to have all these special opportunities, they're getting to have the newspaper come and do a story about this brave sick kid, or they're getting to have a celebrity come and meet them. And that they just find ways to convince themselves that what they're doing somehow actually benefits their child, which is wild to think about. But that sort of is some insight into what's going on in their brain, which I thought was very fascinating and could sort of be a good fit for me.

SPENCER: It's especially ironic because they're essentially torturing their child. But from someone who's coming from the perspective of attention is the most important thing, well, they are getting their child a lot of attention through the child's illness. So maybe on some weird level, they're like, "Well, I'm giving my child the thing that matters, which is they're getting a lot of attention and compassion."

ANDREA: You know, no one has ever said that, and that is such a great insight. Especially because a lot of times, like in my sister's case and in many other cases I've heard about — I do want to say not every person who has Munchausen behaviors will perpetrate on someone else if they have kids. It's not a one to one. It's very common for perpetrators to have Munchausen behaviors in their past, but not everyone who has Munchausen will hurt kids. I think there is something psychopathic going on with people who are able to have a low enough level of empathy to put their child's life at risk, obviously. But that is such an interesting point — Because a lot of times, people with Munchausen behaviors will be willing to put their own health at risk. And they will do things to themselves — make themselves sick — because they need that attention so badly. So that may be part of the justification. That's a great insight.

SPENCER: Let's talk about that empathy point. Because imagine that you really, really care about attention (it is the most important thing to you), you still wouldn't torture yourself, right? Because, well, you have empathy and love for your child and compassion. You wouldn't even torture someone else's child for those reasons, even if it was that important to you. So it feels like it can't just be explained by this really strong drive for attention. There has to be something else around why they are not being limited by their compassion. Is anything known about whether they don't experience empathy, or they have just really diminished empathy?

ANDREA: I certainly think it's pretty accepted that, especially on the extreme end of the spectrum, because there are some of these behaviors and they're all serious, they all affect children negatively. So even if you are only in the fabrication stages, where you're just telling your child they have an illness that they don't have, that's still very damaging to a child's sense of self and their own connection with their body and their ability to trust you as your caretaker. It's all serious. With that said, obviously, not all of this behavior is the same amount of life threatening. I think when you get cases, like the ones we talked about on the podcast, for the most part, which are people who have starved their children, who have poisoned their children, who have taken blood out of their children, these are things that are so depraved that that is the place where this behavior just ceases to be relatable in any way, where you just can't even imagine doing that to your worst enemy, let alone the person that you love and should be the most protective of — your own child. I started working on this project when I was writing my novel that sort of began this whole part of my life when I was pregnant with my daughter. And that's a big part of why that was all got brought up for me. Because I just thought, "Oh my god." It really drove it home for me, how protective you feel of your children and how you would just do anything to stop them from being harmed. And to see your child in pain, as a mother, is the most intolerable thing. I am the biggest baby about even getting my kids their shots, which of course I do, because it's important and all that stuff, but just even sitting there, getting my baby his one-year-old vaccines, I was a mess. It's horrible to watch your children in pain. This has not been studied as much as it could. As you can imagine, this is an incredibly taboo topic. There are a lot of people right now very vocally fighting the idea that this is even a real thing. So it has not been studied. This is not something that's getting big amounts of research dollars or anything. There's so much study, I think, that still needs to be done. For me, in my understanding, not being a clinician or psychiatrist, but the sort of psychopathy/sociopathy element has to be there because there is no way that you could have the capacity for empathy and do these things to your child. I don't see how those two things could coexist. And then you also look at the way that they treat everyone else in their lives. It's not that they're not capable of ever behaving in a loving way towards their children or towards other people, but the genuine empathy, I just don't think is there at all.

SPENCER: One distinction that I think about quite often is the distinction between narcissism and sociopathy, because these two traits (if you want to call them that) have a lot in common. But they're definitely not the same thing. And when I think about Munchausen by Proxy, it strikes me as somewhat more narcissistic than sociopathic, just in the sense that it's so attention seeking. And I think of narcissists as being very attention seeking, whereas sociopaths might be trying to get some goal that they care about, but it's not really so attention directed. So I wonder, is there anything known, or just from your own experience, what links you've seen between this disorder and narcissism?

ANDREA: Yes, there is a known link. There is a high occurrence of Cluster B personality disorders, which includes narcissistic personality disorder. And certainly, you see a lot of those traits in these offenders. So what has been driven home for me about these offenders is that — because I've had to spend a lot of time with it — it's very tempting, even for me, and I think even for people who've worked on this issue for 30, 40 years to believe in some humanity, capacity for redemption. I'm not sure if I believe in that, for the people who have really put their children's lives at risk. I'm just not sure, with some of these behaviors,there's any coming back from it. And that is a really horrible thing to sit with. And that's a personal belief. I just think there are sort of lines that you can cross where you have really forsaken your humanity. And I think putting your child's life at risk to get your emotional needs met is one of those lines. It's not that I don't see the humanity in offenders. I met with Hope Ybarra, who did absolutely monstrous things to her daughter and fortunately was stopped, fortunately was put in prison and has no contact with her children. And they're grown up now. — And I felt a sort of human empathy for her when I was talking to her. She seemed very warm. She seemed genuine when she was saying how sorry she was for what she did. But when I took a step back, I just thought, "No, I think I'm being played here a little bit," or I think she's just trying to elicit that sympathy. And I just think there's a line that you can cross. I think my colleagues who are working on treatment protocols for offenders and work on that side of things, I think that's really noble work, and I really admire them. But I'm not sure how much I think it's possible

SPENCER: You bring up two interesting things here. One is: is it possible to change when you've gone so far. all the way to the point of torturing your child for attention? The other is: is it forgivable? Could someone ever be forgiven in such a circumstance? And I think they're both really interesting questions. On the forgiveness piece, I feel like it'd be very hard to ever forgive someone like that, unless you really knew for sure that they were a completely different person now. An extreme example: imagine that they had a brain tumor, and that is what caused that behavior, and then the brain tumor is removed. And now you know that they would never do it again. Then you're like, "Okay, that was horrible what they did, but somehow, they are no longer that person who did the thing." So I'm wondering what you think about in that kind of scenario where you can really make a clean break and say, yes, they are not the same person anymore?

ANDREA: That's such an interesting question. I've really gone through this evolution in my own life, which has been very painful, where I went from thinking of my sister as — because we were close growing up, and had a happy child with her hood with her, it was not like always this darkness that was sort of looming. She was very well-liked growing up, she had lots of friends, she was very charming, warm and smart, and had very many, many good traits and qualities. And she was a person I loved very much. And I went from thinking at the beginning of this — I loved her, and then at some point, she was gone, like there was a deterioration. There were escalations of those behaviors. And at some point, the person I loved was no longer there. She was no longer someone I recognized. And when I look at it now, I feel like maybe the person I loved was never there to begin with. That is a much harder thing to live with, but I think it's true. Not all my professional colleagues, I think, would agree with that: that this is something that is just sort of in someone. But for me, that has been my experience. And I think with the question of forgiveness, forgiveness means many different things, right? There's the forgiveness that we can have in our own selves and our own hearts just to ease our own suffering, to extinguish our own angst about a situation. And for that, someone doesn't need to ask for that. And then there's the forgiveness that someone asks for. And my sister would say she doesn't do anything to be forgiven for anything, that in fact, I'm the one that should be asking for forgiveness for all the wrong assumptions I've made about her, etc. So in terms of that, that exchange just isn't sort of on the table. I work with survivors now — I have a 501(c)(3) with some of my professional colleagues that offers support groups, and that's been a really wonderful thing. It's been really wonderful to meet survivors and really watch them do their best to move past this. — And I just never failed to be amazed by how strong some of them are. The resilience of people is really incredible. But it's really been interesting to watch them try and decide if they should forgive their own mothers. And to me, I think that they should forgive them if that's going to help them. They shouldn't if it's not. Because I don't think someone that does this is going to change. Unfortunately, it's not as simple as (I say simple like) e removing a brain tumor (obviously, it's not simple). But unfortunately, it's not that simple. I wish it were. I wish this was a chip that could be removed. Because all of us who've been through these situations, and in particular, when I was talking to Hope Ybarra siblings, they had such a similar experience where they're like, "We remember this person that we grew up with, and she was not this. She was not this monster. She was fun and funny and loving. And she was a great role model. And she did this, that, and other good things." And it's really hard to reconcile that those two people could be walking around the same body.

SPENCER: It reminds me of cases of romance scams, where people will get chatted up on your Facebook Messenger (that kind of thing) by an attractive person of the gender they're attracted to. And they'll chat with them over a period of months, and they get to know each other and they'll fall in love. And eventually, the person will ask them for money. And they'll get scammed. And what they'll often discover is that the person that they thought they were in love with never really existed at all. Maybe the person is already married, and they were putting on a whole persona, pretending to be someone else. But I think there's that moment when they realize, "Wait, this person I'm in love with doesn't actually exist. Yes, there is a person at the other end of the line, but that is not the person in my mind." It is that kind of total shock.

ANDREA: Yeah, exactly. And I think I've gone back and forth. And it's been a really constant evolution for me of how I think about all these things. I just have all of these new things to add to my understanding. And I started this podcast project because of my curiosity about all of this, my desire to understand. And I think that I've gotten to a place where I can still hold that I have some really good memories of this person. And I think that's one of the things that can really torture you: that you can think about like, "Well, was there a moment when she started heading down this path and something could have been done?" And that's something I'll never know the answer to, because that's not what happened. And I wish for there to be more study so that if there is some opportunity to intervene when people are doing this behavior to themselves, when they're showing these other sort of traits that might make them susceptible to becoming this, could be headed in a healthier direction, could be taught more healthy coping mechanisms, could really get some help before they're just completely beyond that. But I'm trying to hold both things: that I had a nice childhood with this person, and that this person is...I can't sort of erase the existence of a sibling. We were two years apart. There aren't any family pictures, family memories, anything that doesn't involve her. And so just be able to hold on to a little bit of that, and have it not all be painful to think on, and then also really recognize that this is what happened, and this is not to minimize what came after.

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SPENCER: Looking back at your childhood spent together, are there personality traits that you observed that were maybe precursors of this, whether it's narcissistic personality traits or low empathy, or just a lot of attention seeking even before engaging in the more extreme forms of this behavior?

ANDREA: Yeah. For my parents, looking back, I think that there are a lot of things that they noticed that just didn't just sort of slip by me because I was so young. But I certainly think some of the more histrionic behavior or that sense that if you tried to confront her on something, she would cry and blame you. I think that could be. But a lot of people can have that quality and not go on to do these things. But if anything, part of the thing that was so confusing, certainly by the time we were teenagers, there was a lot of that deceptiveness that was coming up. And there were some behaviors that were really strange, like, where I would see something happen, and then she would tell me a different version of what happened. And it was a completely opposite version, and I just felt confused. So certainly, that's a thing that happened. But in terms of ever having thought of her as a person with low empathy, no. If anything — and I haven't talked to her in a very long time — but probably, still now, I think part of what really pulls people is that she seems incredibly loving. She seems incredibly kind and warm. She was a nurse back when she was younger, and she was, I think, good at that job. I think patients loved her. She seems like a very caring person. So I certainly would never have thought that underneath that, actually, was not real empathy. And now, I believe that it was probably, for a long time, at least in part, a performance of empathy, not actual empathy. But yeah, I certainly would never have thought we would end up here, not in a million years.

SPENCER: What about in terms of attention seeking? Did she have signs of that?

ANDREA: Not any more than really anyone else. I think certainly there were, and again, I don't know which of these things were exaggerated, which were completely fabricated, but when we were teenagers, she had all this stuff with her knee. And then she had surgery. And then she had surgery on her back and had like a weird back brace that she was wearing for a summer. So certainly there was the idea of like — in my mind, my interpretation of it as a kid was — she really likes to play it up when she's got ill, a thing going on. So I think there was that. But again, did that necessarily stand out from other people? I don't know. And again, I was two years younger than her, I was a kid, I was involved in my own whatever I was doing. I just wasn't necessarily watching for it. But also, it's really funny when we talk about attention seeking, because we all want attention. And I think that in the internet age, maybe we are a little bit more poised to understand how strong of a human drive that is, because we see all these social media companies capitalizing on it. It's like, what are they trafficking? They're trafficking likes and reshares. To watch your posts get attention, or watch your podcast go up the charts, or whatever it is, that's a pretty human thing to want attention. I was certainly always a person that maybe more wanted attention for my accomplishments. I wanted to be good at sports and be good at school. And I think I noticed that she wanted maybe more in the sympathy realm, and also that she was very good at giving sympathy. I knew that my sister was a person that I could go to if I had something bad going, like if I had a breakup, or if I had some health thing. She was a nurse, so I used to call her about every little thing I was paranoid about. She was always really good in that role. And so I don't think there were any massive red flags. Now, looking at it through the lens of what I know now, I could probably find some things. But hindsight is a 20/20 kind of thing. I think these just really seemed like personality differences when we were younger. It is funny to be working so deeply in this because just being out in the world, there are plenty of people who really, really like to talk about their ailments and their illnesses, and will tell you about the time they had some illness or their difficult pregnancy or whatever it is, and will talk your ear off about it, who do not have this disorder. There are plenty of people who really like to talk about, and have attention for and sympathy for the things they're going through, but would never take the step of fabricating things or lying about them. It's like there is a range of this that is just sort of normal human behavior.

SPENCER: This set of traits, like any human traits, are gonna lie on the spectrum. And we're talking here about the really far end of the spectrum. And to that point, before we wrap up, I wanted to ask you about your meeting with Hope Ybarra, who you've mentioned a few times. She's maybe the most famous example of this. There was something that really struck me when I was listening to the audio you produced about your meeting. Could you just tell us a story about how you were playing something to her on your phone and what that was like?

ANDREA: Oh, my goodness. Yes, probably the strangest moment during the strangest conversation I've ever had in my life. So I went to meet with Hope Ybarra in a diner in the small town where she lives. This is after many months of going back and forth of her agreeing to do an interview and pulling out and it was a whole drama. We finally got to meet with her, and one of Hope's long running bits (I don't know what you call it, a bit or a con or what have you) claims is that she is deaf. And here's the irony upon irony: I believe she claims she was deaf because of treatment for her cancer, which of course she didn't have. But she says she is deaf. She sort of talks with this strange affectation. She does what I'm told is not actual real sign language. So I knew that she was going to do this. I was prepared for this. She'd done a few other interviews and she'd done this in those interviews, so I knew that was coming. And I really went into my conversation with Hope Ybarra with the tactic that, "I am not going to try to confront this person with facts; that will just shut them down. I want them to give me an interpretation of their experience. I want them to hopefully tell me some emotional truth for them and get their perspective." Because if I sit here and say, "Why did you lie about this? Why did you lie about that," she'll just shut down. So my producer, Tina, and I met up with her, her boyfriend also came, and she was pretending to be deaf. We played along with it, and just said, "Okay, oh, she can read lips, okay, all right." So we were talking about her siblings. And my producer Tina said, "I have some audio of Nick (her younger brother) talking about you and saying some really nice things. Would you like to hear it?" And her boyfriend jumped in and said, "She can't hear it. She's deaf?" And it was this sort of completely strange theater, where we were sitting there and then my producer Tina said, "Okay, we'll turn it up really loud." "Well, she's deaf, she can't hear at all." "Okay, I'll explain what he's saying on the tape so that she can read my lips," and whatever. And we're sitting here and I'm like, "Hope knows she's not deaf. We know Hope knows she is not deaf." I don't know if this boyfriend knows she's not deaf, or if he thinks he's covering for her or what the deal is here. But we all know, she can hear this. And we're playing it. And then Tina is explaining what he's saying. And it was so bizarre. And I was kind of watching her face to see if she was going to react to hearing her brother's voice, who she hasn't talked to in years and years. It was just so strange. And I think the real commitment to the lie is almost like — I think impressive is the wrong word — but you just think, "Why bother?" What is this lie in this moment trying to accomplish? But it's really you can see how much it's a compulsion, like she can't help herself.

SPENCER: It's almost like a character actor stuck in the character permanently.

ANDREA: Yes, and I think to your point, when you asked about whether they believe it, I'm sure that keeping up those big lies really does get to the point where their entire life is a lie. If you are lying about these series of things, and you are lying all the time, and you were lying about all these different things, because it's never isolated. It's always like once you scratch the surface, you find affairs and financial fraud, and they were lying at work, and they lied about their qualifications. And it's like everything. And so, I can only imagine that someone's sense of self must get incredibly eroded over time doing that, because how do you even keep track of who you are or what is true anymore, if you're lying all the time? It must be very difficult.

SPENCER: My last question for you is about people like the boyfriend in this example, with Hope you just mentioned, or people like the partner of your sister, who is, as you mentioned, defending your sister on social media. Clearly, there's an element of involving other people. And because we have such a strong will to believe the people in our life and the idea that they will be lying about so much is so outrageous and so unlikely, can you just talk a bit about how they involve other people sort of in the whole fraud?

ANDREA: It's a really heartbreaking thing. I'm of two minds on it, because I think there's a certain point at which if you've been pulled into this — like Hope Ybarra's boyfriend, who knows what is going on with him, but he may well just believe everything she said and not understand that he shouldn't. Who knows, maybe he doesn't know how to Google things. I don't know. — But, I think there's a certain point where it's very forgivable to get pulled into one of these things. And one of the most heartbreaking things that you see, especially in Munchausen by Proxy cases, is that these perpetrators will infiltrate spaces that are dedicated to parents who are going through the real thing. They will join these groups of parents at hospitals that have kids who have cancer. Because part of the other motivation is to be seen as this heroic parent, they will be leading the fundraiser, and they will be super involved in the organization for whatever disease their child allegedly has. And so they are infiltrating spaces full of people who are really going through these things, and taking advantage of them. And that is heartbreaking. And then for those people, when they realize that it has been a lie, the sense of betrayal upon what is already a horrible situation of having a sick child is obviously horrific. So I think a lot of people can be forgiven for believing a lot of things. I think there is a rubicon, where you have been confronted with enough evidence from enough different sources, where it is no longer acceptable that you are supporting this person. And especially if you are the other parent of those children, as my brother-in-law is. Even with the first investigation, I can see him believing at that point, "Okay, this has all been a misunderstanding. They've got the wrong idea. Her parents have always been mean to her," whatever the justification is that he came up with. What I cannot understand is, being 12 years down the road, she's been investigated a second time for your other child, it went across the exact same pattern, you've had multiple doctors from multiple different institutions calling and reporting to CPS. Once you have all of these people saying your spouse is putting your children at grave risk, if you do not step up and protect those children, that is unforgivable. And that's, I think, where that line is. You mentioned cult leaders earlier, for survivors, they have to go through a kind of an almost cult deprogramming process because that person's influence over them is so strong. And these offenders can be incredibly persuasive and incredibly strong willed and convincing. So I understand how people fall under the spell. But I think once you've been confronted with enough evidence from enough people, then you are then responsible for whether or not you are going to continue to enable that person's behavior. And so I think there is some culpability that eventually enters the chat. And I love that question to ask yourself about anything you feel strongly convicted of: what evidence would it take to change your mind? And if the answer is there's no evidence anyone could produce [sic] me with that would change my mind, then I think that you have gone to a place of belief that has nothing to do with fact anymore.

SPENCER: The analogy to a cult leader is so strong, I think, because cult leaders often cause a great deal of harm. But in addition, they often induce really good people to cause a lot of harm for the belief system. And there's that moment where the victim becomes a perpetrator, who's actually supporting the cult leader in the harm. And they kind of cross that threshold. And once they've crossed that threshold, now, to admit that the cult leader is wrong, is to actually admit that you yourself have caused all of this harm. And similarly, if you've been aiding your wife, who's been torturing your child, at some point, to go back on that and say, "No, my wife is lying," you're suddenly culpable for the torture of your child, which is such a hard thing to admit.

ANDREA: Yeah, I agree. I think there's a line where it would be so annihilating to realize the truth, that you will then do any backflip necessary to find another explanation other than that you've been wrong about this and that you've been aiding this person the whole time. Because I think that that thought is just so intolerable. You couldn't survive it. And that is why you see people sort of getting into — and not just in our case, but in all the cases I've seen, where the person has either a spouse or family members (parents, siblings, whatever) who are supporting them despite even a criminal conviction. — Some people still just say they maintain their innocence no matter what. And I think it's because it would be so intolerable to admit it, that there's sort of no turning back past a certain point. I'm sort of in this opposite, where I'm sort of always worried that I'm wrong. Because I think realizing that I had believed, for instance, that my sister was pregnant, and then finding out that that had all been a lie, that's so profoundly destabilizing. But it's led me, maybe in some ways, a positive way, to really question my beliefs about everything. And I think with this, when I've thought about that with my sister, what would convince me that I'm wrong? Like, what would convince me now that actually I have been wrong this whole time, and there is nothing to this? It would be any other reasonable explanation for all of these events. Any other reasonable explanation. There just isn't one.

SPENCER: Right. If your sister said, "Well, here are the medical records of me being pregnant." That would go a long way; you can prove it pretty easily.

ANDREA: Right. Here's the full medical records for my children. See, none of these doctors actually...I mean, I know that not to be true. But if you could say, "Oh, actually, they have this thing that caused all these things." Because there are instances where people are — and I don't say falsely accused but where they're wrongly suspected — where a doctor will observe some patterns within a child that they think are suspicion for abuse, and then upon further investigation, there is a one-in-a-million medical thing going on. And the moment that that offender is separated from the child and the problem doesn't resolve, it's very obvious the offender is not the cause. Of course that happens. But in those cases, there's an explanation: "Well, we've removed mom, and the issue kept happening. So it's obviously not the mom." It's sort of an Occam's razor thing. Things do tend to make sense. There are medical mysteries, but they don't look like this. They look very different from what this looks like.

SPENCER: Right. When a child goes away from their parents for a few weeks and suddenly recovers, and then goes back and gets sick every time, yeah, that's a little bit of a smoking gun. But I do want to just finish by saying, while I think that this is way under diagnosed, it's also still extremely rare. And if a parent has a sick child, almost every single time, they're gonna be telling the truth about it. Or, at worst, they're just going to be overly worried because they care about their child so much. But these cases of making it up are extremely rare. So we really shouldn't jump to doubting parents when they're telling their children are sick.

ANDREA: What I always want to tell parents, because I have heard that, especially because there's a lot of ballyhoo about sort of false accusations, that I don't think are really false, in most cases. But nonetheless, that is something I've heard from parents: "Should I be worried? Should I be worried that I'm going to take my kid and they have some complex medical thing, and a doctor is gonna accuse me?" And I always tell them, no, absolutely not. Because that is not how doctors think. Something that I always want to reiterate — and this comes from my colleagues, Dr. Carol Jenny, who wrote the original book on medical child abuse — one of the barriers to catching medical child abuse is that it is horrible for doctors to realize that this has happened on their watch. Pediatricians go into pediatrics, because they want to help children. To realize that they have been betrayed by a parent that they trusted and used to harm a child is a horrible thing to have to contemplate for them. So they will often, even in cases where it is legitimate abuse, look for any other explanation, look for anything they might have missed. Maybe it could be this, maybe it could be that. From what I have seen, this is the last thing that doctors want to find. When these cases do get to the case of investigations (especially criminal investigations), it is because of multiple reports from multiple institutions over a period of years. I'm sure there are cases where there are doctors who have made bad assumptions and sort of bad medicine happens, people are jerks to parents, all of those things are real, very real. But this is not something that doctors jump to; this is an absolutely horrible violation for them to endure also, so I don't think it's something people should worry about being scrutinized for if they are not lying to doctors.

SPENCER: Andrea, thanks so much for coming on.

ANDREA: Thank you so much for having me, Spencer.

[outro]

JOSH: A listener asks, "What is one of the biggest challenges you've had to overcome in your life?"

SPENCER: Two things come to mind for that for me. One of them is the challenge of having people who I love experiencing really difficult situations, for example, severe mental health challenges. So that has certainly been really difficult. Having to try to help the people you love, seeing them suffer, feeling like you're unable to help them in their really difficult circumstances, or at least not help them as much as you would want to, and then seeing their suffering continue, that I think really has been some difficult challenges in my life. Another thing is that I'm a worrying-type personality, and so I think I'm the sort of person that my brain tends to scan for danger. Being the kind of person that is always looking for something to worry about, I think, has been a challenge. And thankfully, I've made a ton of progress with that. But still, I would say that I worry more than a typical person, despite having spent years improving. And so I'm much better in that way than I was, but I still wish that I worried less, and it's still a work in progress.

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