by Jodi Picoult
"The majority of victims of Munchausen by Proxy are children. Most often, a mother artificially creates or exaggerates symptoms in a child, and then presents the child for medical care claiming to have no knowledge about the etiology of the problem. The theory of mental-health professionals is that these women do not want to inflict pain on a child, but to indirectly assume the role of the sick person--by getting sympathy from doctors whom they encounter when they bring in the ailing child."
"Whoa," Metz says. "Let's take this a little more slowly. You're saying that the mother makes her own kid sick, just to get attention?"
"That's exactly what it boils down to, Mr. Metz. And making a child sick would be the simpler end of the spectrum. Some mothers contaminate urine samples with blood, create leaks in an IV, or suffocate newborns. Munchausen Syndrome by Proxy is considered a form of child abuse, and there's a nine-percent mortality rate."
"These mothers kill their children?"
"Sometimes," Dr. Birch says. "Unless they can be stopped."
"What are some of the ailments produced by these mothers?"
"Bleeding presents in forty-four percent of MSP cases. Then seizures, forty-two percent. Followed by central-nervous-system depression, apnea, and gastrointestinal disorders. Not to mention psychological symptoms."
"Can you tell us what might trigger this behavior in a mother?"
The doctor shifts in his chair. "Remember, this isn't going to happen to ninety-nine percent of mothers--it's not like a flu virus you come down with. These women are disturbed. Often it's triggered by life stressors--marital conflict, divorce. Perpetrators may have a history of being abused themselves, and they often have some exposure to medical communities, so they know the ins and outs and the lingo. They need--no, they crave support and attention. To them, being sick is a way of being loved and cared for."
"You said psychological symptoms can be produced in a child, too? Can you explain?"
"By symptoms, I mean hallucinations or delusions; memory loss or amnesia; or conversion symptoms, like pseudoblindness. It's harder to understand how a mother can 'fake' them in a child, but basically it involves the mother selectively reinforcing maladaptive behavior. For example, she may provide tremendous nurturing when the child reports a vivid dream and ignore or harm a child when the child is acting perfectly normal. Eventually, the child will learn to give her mother what she wants, so to speak."
"Would it make a difference if that child had only one parent living with her?"
"Absolutely," Birch says. "In fact, it makes parental approval that much more integral."
"So an alleged vision is something that might be reinforced in MSP?"
"Yes, although you'd be more likely to find delusions and hallucinations reinforced in a child if the mother has had some personal experience with either delusions or hallucinations."
"Such as a mother who spent time in a mental institution?"
Dr. Birch nods. "Entirely consistent."
"Doctor, what happens if the mother is confronted with her behavior?"
"Well, they lie and say they're not doing it. In rare cases, the mother may honestly be unaware of her behavior, because she's unconsciously harming the child during a dissociation that occurs as a result of earlier trauma."
"You mean that you could ask these women flat-out if they're hurting their children, and they'll tell you no?"
"They'll all tell you no," Birch says. "It's part of the symptomatology for this disorder."
"So a woman who seems shocked, confused, even righteously angry when confronted with this behavior--a woman with no memory of harming her child--might still have done it?"
"That's correct."
"I see," Metz says slowly. "How do you diagnose MSP, Doctor?"
Dr. Birch sighs. "Carefully, Mr. Metz, and not often enough. Remember, the ones with the presenting symptoms are the children--and they're not going to tell you what's happening, because it's what buys the mother's love. Parents are the primary informants for doctors, who assume their honest report of a child's illness. But most physicians don't make the mental leap and move from trying to diagnose the child to diagnosing the parent.
"Moreover, these mothers don't exactly have scarlet letters on their chests. They deny harming the child and ironically look rather attentive to the child. One way a health-care provider can be tipped off to MSP is to see a long, complicated medical history. Or a description of symptoms that's almost too textbook. Or, in the case of psychological symptoms, to discover that administering drugs doesn't help a whit...since these children of course are not truly psychotic." Birch leans back. "But the only conclusive way to diagnose MSP is to catch the mother in the act--with video cameras rigged in hospital rooms--or to remove the child from the mother's care. Presumably, if it's Munchausen Syndrome by Proxy, the acute illness will remit once the child is taken away."
"Doctor, have you seen Faith White?"
"No, but not for want of trying. I tried to get access to her hospital room three times today but was told she was too ill to speak to me."
"Have you interviewed Mariah White?"
"No, I've reviewed information on her institutionalization and her current mental health."
"Does Mariah White fit the profile of a perpetrator of MSP?"
"In many ways. The behaviors in her child ensued after a period of great personal stress. Mrs. White has seemed a concerned parent, taking her daughter for psychiatric treatment--which, note, did not respond to drug therapy--and to the emergency room. And perhaps what is most telling, in this case, is the choice of stigmata as a presenting ailment. Bleeding is easy to produce in a victim, yet stigmata are fairly brilliant. It has to be a symptom with a textbook description, because there aren't any chronicled cases. What physician can say that the child's not a stigmatic, when he's never seen one in his life?"
"Is that all, Doctor?"
"No. Mrs. White also has a history of mental-health problems. As a result of marital stress, she attempted to commit suicide--and suddenly a hundred doctors and nurses were there for her support. On some level she equates being loved and taken care of with attention from health-care personnel. Which could explain why, when a similar marital stress occurred, she began to make her child sick. Every time she brings Faith in to be treated, Mrs. White herself, by proxy, receives the attention she got seven years ago from doctors and psychiatrists."
"Could she be hurting her daughter and not know it?" Metz asks.
The doctor shrugs. "Not having examined her, it's difficult to say. But it's possible. Mrs. White suffered from severe depression before, and the shock of finding her husband involved in another extramarital affair might be enough to cause a dissociative break. Rather than face the pain all over again, she absents herself mentally. It's during these episodes that she feels most neglected, and therefore it's during these episodes that she harms her daughter."
"What do you imagine would happen if you confronted Mrs. White with this behavior?"
"She'd flatly deny it. She'd be very upset that I would accuse her of something so heinous. She'd tell me that she loves her daughter and only wants her to be healthy."
Metz stops at the defense table. "Dr. Birch, as you know, Faith is in the hospital. If her mother were allowed no contact with her for a period of time, what would you expect to happen?"
The psychiatrist sighs. "I wouldn't be at all surprised to see Faith White bounce back to health."
December 3, 1999--Late afternoon
After the court empties, Joan and I are left sitting alone. "What are you going to do now?" she asks.
"I'm not going to go to the hospital, if that's what you mean."
"It wasn't. I just...well, I didn't know if you had other plans."
I smile at her. "I was thinking of going home, taking a hot bath, and then sticking my head in a gas oven."
"Not funny." She touches my arm. "Do you want me to call Dr. Johansen for you? I'm sure, given the circumstances, he could squeeze you in for an ap
pointment, just to talk."
"No. Thanks."
"Then let's go out for a drink."
"Joan," I say, "I appreciate this. But I don't feel like having company right now."
"Well, I'm going to go to the hospital to check on Faith. I'll fill your mother in on the court order and ask her to call you at home."
I thank Joan and tell her I'm going to sit for another moment, and then I listen to her heels click down the long aisle of the courtroom. Resting my head on the table, I close my eyes. I try very hard to picture Faith. If I do, maybe she will know that I'm here, thinking of her.
When the custodian comes in with the machine that buffs the floor, I leave, surprised to find a bustle of activity in the hallways and lobby of the courthouse. Just because our hearing is finished for the day does not mean anyone else's is. Leaning against a wall is a weeping woman, an elderly man with his arm ratcheted over her shoulders. Three toddlers weave through a bank of plastic chairs. A teenager hunches like a question mark over the receiver of the pay phone, whispering furiously.
Although I don't want to see Ian, it is still a disappointment not to find him waiting.
It has started to snow, the first snow of the winter. The flakes are thick and fat; they melt against the pavement as if I have only been dreaming them. I am so caught up in the beauty of it that I do not notice Ian standing beside my car until I am only a few feet away.
"I have to talk to you," he says.
"No, you don't."
He grasps my arm. "Aren't you going to speak to me?"
"Do you really want me to, Ian? Do you want me to thank you for calling that idiot reporter from the Globe and getting him to dig up Greenhaven, so that Malcolm Metz could twist it into some sick psychological disorder I have that makes me mutilate my own child?"
"If I hadn't called, Metz would have dug it up by himself."
"Don't you dare make excuses," I say, my voice low.
I get into the car and try to close the door, but Ian holds it fast. "I think I'm in love with you," he says.
"And why is that? Because I had the good fortune to give birth to an extraordinary child you could use to boost your show's ratings?"
"What did you want me to say? I didn't know you when I called McManus. Afterward, I didn't want to tell you, because I thought you'd hate me for it. And as for what I said about Faith--well, Christ, I had to be vague. I thought the last thing you wanted was for me to tell the world that I believe Faith can heal."
"Somehow, Ian, I have a hard time believing you had Faith in mind up there on the stand. I have a hard time believing you were thinking of anything but your show-biz reputation."
A muscle jumps along Ian's jaw. "All right, maybe I was. But I was also thinking of Faith. And you. What do I have to do to convince you? I'll give the money Metz paid me to Faith's college fund...or to the frigging Jesuits. I'll go public saying whatever you want. I made a mistake, and I'm sorry. Why can't you just believe me?"
Because, I want to say. Because of what's happened to Faith. She believed, and look at where it's gotten her.
"Mariah," Ian begs hoarsely, "let me come home with you."
With a tremendous yank, I manage to pull the door out of his grasp. "You can't always get what you want," I say. "Not even you."
Let me tell you what you feel like when you know you are ready to die.
You sleep a lot, and when you wake up the very first thought in your head is that you wish you could go back to bed.
You go entire days without eating, because food is a commodity that keeps you here.
You read the same page a hundred times.
You rewind your life like a videocassette and see things that make you weep, things that make you pause, but nothing that makes you want to play it forward.
You forget to comb your hair, to shower, to dress.
And then one day, when you make the decision that you have enough energy left in you to do this one, last, monumental thing, there comes a peace. Suddenly you are counting moments as you haven't for months. Suddenly you have a secret that makes you smile, that makes people say you look wonderful, although you feel like a shell--brittle and capable of cracking into a thousand pieces.
I was looking forward to dying. I remember holding the razor blade and hoping to make the cleanest, deepest cut. I remember calculating how long it would be until I heard the voices of angels. I wanted nothing more than to be rid of myself, of this body and this person who had nothing coming to her but pain.
In short, I have been there. I, of all people, should understand wanting to give up, when the ache is too great. But instead I feel myself fighting furiously, grasping at straws to keep Faith from succeeding where I once failed.
"Her temp's at one-oh-six. Something's got to give."
As if the doctor's words have prompted it, Faith's limbs stiffen, and she begins to thrash from side to side. "She's going into seizures," the doctor calls out. A nurse gently pulls Millie away from the bedside. "Ma'am, I'm going to have to get in here."
The doctor holds down one of Faith's wrists. The nurse holds the other one. Faith's body continues to buck and heave, with the jerky rhythm of an amusement-park ride. "She's bleeding again," the nurse murmurs.
"I want pressure and elevation," the doctor calls, and the bed levitates with the push of a button as two nurses begin to press against her palms.
High-pitched beeps suddenly break the flurry of activity and make Millie jerk her head toward the monitors behind Faith's bed. "She's coding. Get a cart!" The doctor moves to the side of the bed and starts to perform manual CPR.
Within minutes, the room is filled with nurses and doctors. "Ressler, bag her and intubate her. Chest compressions at fifteen per minute." The doctor checks the rhythm of Faith's heartbeat and continues shouting orders. "Wyatt, put in a central line and pour in lactated Ringer's as fast as it'll go, for one liter. And Abby, I want a CBC, platelets, and a clot sent to the blood bank for type and cross."
"Ma'am, why don't you come with me, so we can help her?" The nurse tugs Millie out to the hall, where she stands with her face pressed to the glass of the pediatric ICU. Millie watches someone rip open Faith's hospital johnny and set defibrillator paddles on her small chest. She does not realize that her hand has crept up to cover her own strong heart.
A half hour later
Joan sits beside Millie in the patient lounge. She's never liked hospitals; this one is no different but there's something she can't put her finger on that seems even more unnerving than usual. She smiles gently at Mariah's mother, encouraging her to continue.
"The doctor," Millie tearfully relates, "says that she has an excellent prognosis because she spent less than a minute in cardiac arrest. Her airway's clear, and her rhythm's been steady."
Joan glances at the girl, limp on the hospital bed. "She doesn't look good."
"But they've got her heart under control, and her fever is down. The only thing they can't stop is the bleeding." Millie takes a deep breath. "So how long before Mariah gets here?"
"Actually, that's why I needed to speak to you. Mariah can't come to the hospital."
"Did something happen? Is she all right?"
"She's fine. She's just under a restraining order, courtesy of the judge and Malcolm Metz. They think she's causing Faith's symptoms."
"That's...that's ridiculous!" Millie sputters.
"You and I know that, but you don't mess with a restraining order. I'm going to need you to stay with Faith and call Mariah with updates."
"She can't even call?"
Joan shakes her head.
"This must be killing her." Millie rubs her temples, clearly torn between keeping watch over her granddaughter and going to her own child to provide emotional support.
Joan glances down the hallway. It suddenly hits her: The strange thing about this pediatric ICU ward is that Faith is the only patient in it. With the exception of the doctors and nurses called in for Faith, there's no one around. "When you call--"
/>
"I won't make it sound this bad," Millie says. "I'm not a fool."
Colin walks into the darkened ICU room and stands at the foot of his daughter's bed.
Her arms are spread wide, loosely tied with restraints to the bed-rails to keep the wounds in her palms from reopening. Her feet are anchored by the blanket. His eyes touch upon the wires taped to her chest, the tube in her throat, the gauze pads cupped in her hands.
He does not know what to believe. He listens to the doctors when they speak to him. He listened to that psychiatrist, Birch. And he listens to Mariah when she swears she'd never hurt Faith. Colin sits gently on the bed next to Faith.
"'Hush little baby, don't say a word. Daddy's gonna buy you a mockingbird.'" He presses his wet cheek against Faith's, hears the steady beep of the monitor attached to her chest. "'If that mockingbird don't sing, Daddy's gonna buy you a diamond ring.'"
The doctors told him that Faith's heart gave out. That with all the stress put on it by the other failing systems of her body, it simply stopped.
He knows what that feels like. He would drop the custody case this minute if it meant Faith would walk out of the hospital as healthy and hale as any seven-year-old.
He leans down and awkwardly wraps her in his arms. "Hug me back," he whispers, and then more forcefully, "Come on." Just one slight twitch and he'll be happy. He shakes her a little, urging her to consciousness, but then a nurse is beside him and pulling him from the bed. "You need to let her rest, Mr. White."
"I want her to hold me. I just want her to do that one thing."
"She can't," the nurse says. "Her hands are tied." And while Colin is still turning that phrase over in his mind, she ushers him out of the room.
"You're telling me everything?" I ask, hanging on to the receiver of the portable phone so tightly I must be leaving nail marks.
"Would I lie to you?" my mother answers. "She's in there sleeping."
"So she hasn't gotten better, but she hasn't gotten worse." Stability I can handle. It is having to sit idly while Faith is in trouble that sends me over the edge.
"Kenzie van der Hoven's here," my mother says. "She's been at the hospital for an hour."
"Did that idiot psychiatrist show up?"
"The one who kept coming all day? No."