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David B Allison and Mark S Roberts, New Jersey, USA, The Analytic Press Inc, 1998, 279 pages, £31.95.
Munchausen By Proxy Syndrome (MBPS) or Munchausen Syndrome By Proxy as Meadow termed it is one of the current controversial areas of child abuse. Its diagnosis or its very existence generates as much debate as that produced by the diagnosis of sexual abuse in the 1980s.
This book, whose authors are philosophers at the State University of New York, at Stony Brook, sets out to question the assumption on which the syndrome is based. They argue that the syndrome is essentially false and the evidence sustaining it insubstantial and logically flawed. This book is aimed at physicians - adult as well as paediatricians since it also considers Munchausen's Syndrome - and social and cultural theorists. The first part of the book is concerned with arguing that the construction of some disorders for example, witchcraft, hysteria and MBPS have more to do with medicine's - and in particular psychiatry's - attempt to contain and control challenging behaviour (especially in women) which has no obvious organic basis. In so doing the authors attack the philosophy and assumptions which underpin the American Diagnostic and Statistical Manual - Mental Disorders and the formulation of MBPS as a disorder.
In part two, the historical and textural precedents of Munchausen Syndrome and MBPS are traced. The authors argue that the diagnosis has more to do with practical issues of administration, maintenance of social bias, the exercise of punishment and social control than it has to do with medical science. From their perspective MBPS has defined itself into existence by its extensive uncritical literature for example, incomplete case reports. It could of course be argued that this dependence on precedents, prior to formulation of generalisable hypotheses which can be tested, underpins much of medical science. One of the difficulties with MBPS is the lack of a coherent theory of causation; yet there are other medical syndromes for example, Alagille's Syndrome, (biliary hypoplasia) where specific causation may not be recognised.
The third part of the book is devoted to a criticism of what has become the American standard text on MBPS, namely Schreier and Libow's Hurting For Love and in particular its theory of motivation. There is detailed discussion of two American cases, namely the cases of “Christopher” and “Mrs Eldridge”. Although the analysis of the cases is detailed readers who are not familiar with them will wish for a balanced summary of the facts. Ironically, this is a criticism which Allison and Roberts level at literature on Munchausen Syndrome By Proxy.
Overall, this is a thought-provoking book which, as the title suggests, is written from the mothers' perspective. It is written with passion but some might find the style too polemical for their taste. For example, an assertion is made that doctors in the US system “essentially created all the gynaecological myths and procedures directed against women in the first place” (page 184). Mother/child bonding is given as an example of a means of controlling women and re-establishing the centrality of the paediatrician and obstetrician. It could be counter-argued that much of the force of the bioethics movement of the last two decades has been directed against such biases. It could also be argued that welfare recipients, at least in the UK, can exaggerate or mis-report a child's symptoms in order to obtain benefits.
Perhaps understandably, given the perspective of this book, the ethical difficulties faced by professionals when they suspect deception do not receive much attention; even though, by accepting fabricated accounts professionals may “abuse” children by carrying out unnecessary investigation or treatment. Discussion of covert video surveillance only appears towards the end of the book. Emminson's and Postlethwaite's analysis of MBPS as part of the factitious illness spectrum of disordered behaviour is not mentioned.
In their final chapter the authors acknowledge that parents may use medical means to abuse their children and emphasise the need for professionals to examine and attempt to understand the socioeconomic context, motivation and psychopathology. Whilst few would quarrel with these conclusions, I suspect that many, though having sympathy with the arguments in this book, would find them difficult to accept in their entirety. Perhaps there is a “third way”?