Warning: Sharp Objects spoilers ahead!
We’ve seen a lot of Munchausen by proxy plotlines onscreen this year, from the twisted pas de deux of Phantom Thread to the devastating child abuse of HBO’s Sharp Objects. Munchausen by proxy is a form of abuse in which a caregiver either fabricates or causes sickness in the person (usually a child) that they are caring for. And in the last two episodes of Sharp Objects, we learned what book readers had known all along: that Adora (Patricia Clarkson) has been poisoning her daughter Amma, and that she was also responsible for the death of her younger daughter, Marion. But did she also kill two other Wind Gap girls, or, as the finale suggests, did Amma inherit some of her murderous impulses? I called up Marc D. Feldman, an expert in Munchausen by proxy, and the author of Dying to be Ill: True Stories of Medical Deception, to discuss Adora’s pathology and what Sharp Objects gets right and wrong about this form of abuse.
Did the show’s depiction feal realistic to you?
I thought the single most realistic element was Alan Crellin, the husband. Before I knew about the Munchausen by proxy plot element, I thought he was so nondescript. But now I realize that’s exactly right, that’s how these husbands tend to be: by living with a powerful, demanding, self-absorbed spouse, they learn just keep quiet and to ignore what’s going on in front of them. Often these parents maintain a traditional marriage when it comes to the children, where the father cedes authority over the children to the mother. So he put on blinders, and they were very effective.
What about Adora, did her character feel convincing to you?
Adora seemed just to crave the maternal role. Sometimes Munchausen by Proxy has been called a perversion of mothering, and that’s what we saw here — it’s a caricature of mothering. Superficially, Adora appears to be mother-of-the-year, and yet throughout all of her behaviors is a tendency for deviousness and control. Now in terms of Marion’s dying, about 9 percent to 10 percent of the children victimized by Munchausen by proxy die as a result of the abuse, so Marion’s death would be a little atypical for the outcome of one of these cases. But what’s true is that these mothers generally get away with it. Despite Marion’s death, had Adora just stopped there, she would have gotten away with it.
In terms of when children die from Munchausen’s by proxy abuse, is there some level of gratification that comes from being the parent of a dead child? Like, is it usually unintended or is that part of the pathology?
Both can be true, but generally the child’s death is not what a Munchausen-by-proxy mother is seeking. In fact, death removes the object of her deceptions. She can no longer falsify or induce illness in somebody who’s died. But I’ve also dealt with cases where mothers just love bereavement festivities, and they fall in love with the attention they get. They enjoy leaving the impression that fate has been terribly unkind to them despite being exemplary parents. There’s a case of Marie Noe in Pennsylvania, she killed ten of her children. She loved that role of appearing to be the most bereaved mother in American history.
In the book you talk about how MBP, or medical child abuse as it’s more commonly called, can be either rooted in hatred of the child or some twisted way of showing love. What do you see happening here?
Adora’s focus on other people’s perceptions of her is obviously pathological. I think most of these mothers have real limitations in their love for their children because they objectify their children so much. They see their children as objects to be manipulated. Camille was not a submissive child, and Adora admits, “I never loved you.” She wanted somebody whom she could much more easily objectify and manipulate.
Based on your experience as a clinician, what interpretation did you make of the ending?
A significant minority of people who are victimized by Munchausen by proxy do go on to become perpetrators, but it is a minority. I sometimes hear from survivors who ask me via email, “Am I destined to abuse my children?” And that’s just not the case. It isn’t just something that happens to a person; as you could see with Adora and her careful measuring of the chemicals to be fed to the daughters, there’s often really considerable planning and caretaking, and that proves that it’s not motivated or prompted by delusions, or schizophrenia, or other kinds of psychosis. It’s deliberate planned behavior for which they are always culpable.
One thing I was struck by, if we do assume from the ending that Amma was a murderer, then we have this family of three women, and one of them is lashing out by causing harm to her children, Camille is processing her pain by harming herself, and then Amma is dealing with her pain by harming others. It seems like there’s three different ways that harm can be weaponized, or turned inward or outward.
That’s a really good point, yeah. I actually used to study self-mutilation as my main area before I moved to factitious disorder and Munchausen syndrome, and Munchausen by proxy. I became fascinated with why people would cut themselves. I think many of the self-mutilators would love to strike out violently, but they contain their impulses and instead direct them internally. I think many of them are always somewhat suicidal, and they sacrifice their skin, or they burn themselves, or they amputate a body part, or they do various things to avoid committing suicide.
We studied groups of Munchausen by proxy children as they became adults. Some became perpetrators themselves and others became Munchausen patients, meaning they made themselves sick for attention as if to master the original trauma. But some avoid all medical environments, and avoid even medically necessary treatment because of post-traumatic stress disorder — which Camille clearly had, as you can see in all the flashbacks.
Regarding Amma, is it credible that someone who suffered this kind of abuse as a child would go on to be quite disturbed throughout their lives?
Yes. Some of them have disturbances in reality testing, which just means that they are often quasi-psychotic and they can lose touch with reality pretty easily. Those are the most extreme cases.
We’ve seen a lot of Munchausen story lines in pop-culture recently, but how common is it, really?
Even in the articles I’ve read about Sharp Objects the syndrome is referred to as astonishingly rare, but I think it’s just woefully underdiagnosed. There are still people who say it doesn’t exist, and there are advocacy groups for accused mothers that claim it’s an invention of mental-health practitioners who love tearing nursing babies away from their mothers. But it does occur. I want people to know about it, and not view it as mysterious or dubious.