Intervention by Separation and Reunification of Victims of Munchausen Syndrome by Proxy

: This study aims to analyze the impact of the intervention method by separating and reunifications children as victims of Munchausen Syndrome by Proxy against their parents as perpetrators of Munchausen Syndrome by Proxy. The subjects of this study were 9 expert figures with different backgrounds and several previous research journals as references. This research uses interpretative analysis by using an unstructured interview method and journal review for secondary data. After the data is collected completely and thoroughly, both from primary and secondary data collection, the data can be grouped or adjusted according to the type of data obtained from interviews with research subjects and previous research based on the journals. The results showed that the separation intervention is still one of the intervention methods used for victims of child abuse. However, this intervention can also cause deep psychological wounds in children due to being separated from their parents, where the trauma from the separation will greatly affect the psychological development of children in terms of their trust in others. Apart from that, reunification is still very possible


Introduction
Acts of violence or forms of abuse against children have become a major issue among cases of violence because children are the most vulnerable part of society, and this vulnerability makes them uncomplicated targets for acts of violence or harassment. Acts of physical violence against children have a wide spectrum ranging from beatings to sexual abuse and even causing child death. According to Polat (2017), the range of acts of violence against children is very wide. In physical violence, an act that begins with a slap can end in an act of killing. As Polat explains, physical violence against children is a broad term and must be defined and recognized within a specific framework to protect children and punish perpetrators.
As one form of violence against children, is Munchausen Syndrome by Proxy (MSBP). MSBP is a psychological disorder characterized by attention-seeking behavior by caregivers through those in their care (Bretz & Richards, 2000). MSBP perpetrators usually seek attention and psychological satisfaction from their actions, where financial gain is not the main goal of the violence committed. Cases of violence that are classified as MSBP are forms of violence that are invisible but have a very real impact that can affect all aspects of a child's life without them realizing it. This condition affects the primary caregiver, often the mother. People with MSBP gain attention by seeking medical help for child symptoms that are exaggerated or artificial in their care. People with MSBP can create or exaggerate a child's symptoms in various ways so that the child exhibits the symptoms the offender wants. MSBP may not be widely known by the public because MSBP cases are not easily diagnosed by medical personnel. One of the main causes is because most of the perpetrators of MSBP's actions are mothers of children or victims, and of course mothers are seen as child protectors. As a result of this general perception of the mother, suspecting the mother of being the perpetrator of violence is not something doctors will consider when a child suffers from a prolonged illness or with reports of several complications of the child's illness (Lanzarone, et al, 2017). Another problem is that even if a doctor has a suspicion of a fictional story about a child's illness, the doctor must be able to substantiate and convince the authorities with medical evidence, and in this situation, it is very important to collaborate with specialist doctors or other medical staff on the credibility of the story. medical treatment told by the mother of the sick/victim child (Akpinar, 2021). MSBP is known by many names and is considered the deadliest form of child abuse. Wright (1987;in Siegel & Fischer, 2010) suggests that MSBP is a condition that represents abusive parenting and involves excessive health-seeking behavior patterns that endanger the health, safety, and sometimes survival of children. Doctors and researchers struggle to separate this condition from other conditions of child abuse, with the main symptoms identified being (1) a child's guardian (usually the mother) concocts or causes illness in the child to obtain unneeded medical care for the child and (2) abnormal personality characteristics of guardians who commit acts of falsifying the child's health condition. The fact that at least two people are involved in this syndrome, the child perpetrator and victim, makes it difficult to define. Child advocates use names that focus on the child abuse aspect of the condition, while psychologists are more interested in establishing and naming a mental health diagnosis for the offender (Wahi, et al, 2017).
MSBP is a concept that has been around for a long time but is relatively new in its application and classification as a form of violent behavior in Indonesia. Current literacy regarding MSBP itself is still very rare, especially in Indonesia, where research or case studies regarding MSBP have not been widely carried out. As a result, it is quite difficult to find cases that can be classified as a form of MSBP in Indonesia. In addition to the fact that there are no official cases recorded as a form of violence against MSBP in Indonesia, most of the experts concerned also do not know the basic concept of MSBP as a form of violence against children. This condition further complicates the diagnosis of MSBP, especially in Indonesia, because the perpetrators of these MSBP actions can easily be seen as parents who are very concerned about their child's illness without suspecting that there was an intentional violation by the parents to worsen the child's health condition (Paramita, 2021).
According to Sousa, et al (2017), generally, actors will report their stories dramatically, but when asked to explain in more detail their stories will become blurry and inconsistent and change every time they are asked. However, what makes the situation even more difficult is the tendency for perpetrators to have extensive knowledge of medical terminology, routines and hospital protocols which makes the stories of their false diagnoses very convincing in the eyes of the medical authorities concerned. The perpetrator may lie about the symptoms of the child in their care by altering the test (such as contaminating a urine sample), falsifying medical records, or the perpetrator may even cause or produce the desired symptom in various ways, such as making the victim appear poisoned, reducing nutritional intake, and so on so that children look weak and perform actions that can cause mild or severe infections in victims (Steel, 2009). MSBP has two distinct categories, which are referred to as "simulation or mild form" and "production or severe form" (Brown et al., 2009). Simulation occurs when the perpetrator makes a history of a disease or condition that does not exist in the child. While production is an intentional act of making a wound so that it causes signs and symptoms of the disease that the perpetrator wants to appear in the child in his care.
A major hurdle in defining MSBP is that it is difficult to distinguish between parents with MSBP and parents who are overly concerned about their child's health, who will interpret every minor symptom as a serious illness, developmental problem, or mental health problem. Parents who engage in MSBP should also be distinguished from parents who are frustrated by the fact that there are limits to what can be done for their children (who do have certain illnesses) and struggle to get better and more appropriate services for their children. The main difference that might be seen is that MSBP is a form of deviation or an act of violence against children and not parents who are worried about their child's illness. The diagnosis given will depend on whether the parents created or caused physical illness in their child or not (Ayoub et al., 2002).
According to Wahi, et al (2017), in the evolution of this understanding of MSBP violence, the main focus is often on perpetrators, not victims, even though victims experience high death rates, and many believe that perpetrators cannot be treated. Studies of child victims have been hampered by the general inability of systems designed to protect children from violence, such as the medical system and child protection systems, to successfully intervene to protect victims. In many identified cases of violence against MSBP where there was clear evidence of violence, the victim was unable to be separated from the perpetrator, and follow-up action against the victim was not possible. For various reasons, including the fact that when cases were identified, the victims were found to have had siblings who had died (it is believed that many of the victims identified were dead or had severe disabilities). Without follow-up, little is known about the actual death rate of victims, although studies of cases of infant death due to violence against MSBP, initially misclassified as Sudden Infant Death Syndrome (SIDS), show that the death rate is high.
Even though MSBP is a form of violence against children, the handling of cases cannot be equated with other forms of violence against children in general. MSBP is a form of violence that is quite complex, where every aspect is very thick with psychological elements, both for perpetrators and victims, so that appropriate and sustainable forms of intervention are needed in handling these cases. Unfortunately for children who are victims of acts of violence, one of them is MSBP, some of the interventions have had fewer positive results or even had quite a negative impact. After a case of violence has been found and sufficient evidence has been collected to build a legal case, the child is usually taken from the main family to be given protection and finally placed in a home away from the perpetrator. For children, this condition can be a traumatic experience, because visits by perpetrators who are usually the child's parents are no longer allowed and family reunification is not possible at that time because parents as perpetrators still have to undergo legal proceedings in court. Children who have experienced acts of medical violence such as MSBP must then overcome the trauma of being taken from home and separated from their parents. The emotional effects of a child as a victim of MSBP's actions may not be apparent after separation from the perpetrator is in effect at the time but can manifest for years after the violence has stopped. Child victims of MSBP's actions may experience trust problems due to feelings of "betrayal" by their parents, as well as long-term physical damage caused by the perpetrator's actions towards them (Shaw et al., 2008). Thus, interventions by only separating children without carrying out counseling or other forms of assistance in a sustainable period of time are likely to further worsen the psychological health conditions of the children.

Research Methods
This study uses qualitative research methods with a phenomenological approach and purposive sampling techniques in selecting research subjects. The purposive technique was chosen because there are still very few experts in Indonesia who can become research subjects who have in-depth expertise on MSBP so that in other words the subjects contacted are adapted to certain criteria that are applied based on their respective expertise or profession which are still suitable for research needs in answering questions. study. At the stage of seeking sources, one of the obstacles encountered by researchers was the difficulty in finding relevant expert figures who were willing to be interviewed regarding their understanding and opinions of new forms of violence such as MSBP. Most of this reluctance occurred because the expert figures who wished to serve as resource persons were hesitant to express their opinions on topics that they were not familiar with. By using a purposive sampling technique, 9 experts were found who were willing to become research subjects as resource persons in the interview stage. The resource persons consisted of prosecutors, police, pediatricians, clinical psychologists, forensic psychologists, as well as members of social and community institutions related to violence against children and their protection. In addition to conducting interviews with 9 predetermined sources, the researchers also reviewed several previous research journals regarding the forms of intervention that could be carried out on MSBP victims. Because there are no research journals on MSBP acts of violence in Indonesia, all reading reference materials fully use journal references from cases and research results in other countries.
Most of the data mining process was carried out online to comply with social distancing protocols during the COVID-19 pandemic lockdown. Of the 9 (nine) interviewees, there were 3 (three) interviewees who conducted the interview process offline, by carrying out the booking process and prior permission to be able to meet the interviewees and be present at a predetermined location. Each resource person will be given 7-10 questions that are tailored to the focus of the professional field of each resource person. Interview duration ranged from 45 -60 minutes, where for offline interviews audio recording was carried out and for online interviews video recording was carried out. The recording process is already with the approval of each relevant source. For additional or follow-up interviews, if needed, it will be conducted online for 1 additional session (approximately 45-60 minutes in duration).
The data obtained through an unstructured interview process were then analyzed using interpretive analysis. According to Sugiyono (2010), interpretive research analysis focuses on the subjective nature of the social world and tries to understand the frame of mind of the object being studied. After the data has been collected completely and thoroughly both from primary and secondary data collection so that the data can be grouped or adjusted according to the type of data obtained from interviews with informants and reviews of previous research journals. The process can be repeated until the research results cover all the results and information that the researcher wants to explore. Data verification can be carried out using information obtained when conducting interviews with informants or conducting document reviews from journals and previous studies. Based on the results of interviews with 9 informants who were interviewed, six out of nine informants understood MSBP. The level of understanding of the six informants varied from quite understanding to very understanding. Three of the nine informants did not have an understanding of MSBP and were not even able to differentiate between MSBP and acts of child abuse in general. Such ignorance may result in a lack of awareness of MSBP among professionals involved in the victim's health care which may lead to a more rapid diagnosis but would be off target. Paturej, et al (2019) noted in their research that the true scale of MSBP's actions remains unknown due to underdiagnosis of the disorder. Caution is required in cases of extensive medical history, such as disproportionate laboratory findings and significant patient social history (mental illness, childhood trauma). This understanding will make it possible to avoid some unnecessary tests and provide caregivers with therapy that can ultimately prevent further abuse of children.

Results and Discussion
Seven out of nine informants stated that the handling of cases such as MSBP required a special form of policy. This was deemed necessary because of the complexity of the MSBP case itself, where the handling of cases such as cases of violence against children was generally considered inappropriate when applied to MSBP situations. One of the problems that the researchers found when conducting interviews with 9 experts was the lack of understanding of the experts about the MSBP concept itself. The greatest lack of understanding was found among the interviewees who worked as prosecutors and police. This condition is very unfortunate because a lack of understanding will facilitate the loss of the focus of the investigation and add other elements to the investigation which can divert the focus of the investigation from the original purpose of why the case needs to be handled. A blurred focus will cause the forms of treatment and intervention given to both perpetrators and victims to be inaccurate and inappropriate for dealing with cases of MSBP violence (Paramita, 2021).
According to Wahi, et al (2017), MSBP's acts of violence were basically attempted murder, so there should be no difficulty in getting the perpetrators arrested by law enforcement after strong evidence of violence was found. Wahi's statement can also be supported by a theory in criminology, namely Choice Theory. Choice Theory assumes that criminals carefully choose whether to commit a crime or not based on considerations they can think of rationally or habits and other influencing environmental aspects (Seigel, 2000). One theory that is a branch of Choice Theory is Rational Choice Theory (Rational Choice Theory). According to McCarthy & Chaudhary (2014), rational choice theory refers to a set of ideas about the relationship between individual preferences and the choices they make. When it comes to crime, the theory assumes that crime can be understood "as if" individuals choose to commit crimes using the same cost-benefit analysis principles that they use when choosing legal behavior. Thus, the decision to commit a crime is influenced by individual preferences, their attitude towards the risks that can be posed, their estimates of availability, costs, and opportunities.
The characteristic feature of MSBP's actions is the perpetrator's desire to get attention or the desire to be the main center of attention for the environment around them, so they will do everything they can to get that attention, even by hurting their own children. This attention-seeking act has definitive similarities to histrionic personality disorder (HPD). According to DSM-5 (in APA 5th Ed, 2013), HPD is a form of personality disorder characterized by excessive attention-seeking behavior patterns. Individuals with HPD are said to be "lively", dramatic, lively, enthusiastic, and love to seduce. HPD lies in the dramatic group of personality disorders. Features of this personality disorder include a tendency to have egocentrism, self-indulgence, a persistent desire for recognition, and persistent manipulative behavior to achieve their own needs (APA, 2013).
Someone with a personality disorder will be consciously aware of all the treatment or actions they are doing because they have considered most of the aspects involved as a strategy to get what they want. If it is associated with the previous rational choice theory, the MSBP perpetrator uses rational choice theory in deciding what actions he will use to carry out his crime so that his desire to get attention can be fulfilled. When an individual knowingly commits a crime, then based on the law, that behavior can be punished, of course with the support of supporting evidence. This evidence is only available through a detailed and thorough healthcare system in recording the patient's medical history, which is the weapon used in the attempted murder by the perpetrators of MSBP. Therefore, this evidence must be provided to law enforcers so that charges of attempted murder can be filed against the perpetrators and the level of understanding of each of the relevant experts is also the key to success in making an early diagnosis of suspicions of MSBP's actions that have occurred.
Regarding the form of intervention that can be provided in MSBP cases, each informant has his own choice. However, overall, the subjects said that psychological counseling to perpetrators and victims and the separation of victims from their main caregivers who performed MSBP were the main forms of intervention that should have been the goal of the trial. Victims of violence against MSBP, like other victims of violence, require extensive rehabilitative care after being released from situations of violence. There is almost no discussion of the responsibility of the health care system in providing such care after MSBP acts of violence were identified from the existing scientific literature (Wahi, et al, 2017).
In Indonesia itself, the LPSK (The Witness and Victim Protection Agency) has often carried out a form of separating victims from their parents as perpetrators of violence, but interventions such as counseling, assistance from psychologists and social institutions are usually only given for six months while the case is being processed in court. Currently, the LPSK has not been able to carry out further studies on the victims of child abuse it has handled due to a lack of resources from the LPSK itself. In fact, for cases like MSBP, the forms of assistance and interventions provided must be long-term, not just 6 months. This was also stated by Berg and Jones (1999) in their research, where they conducted a follow-up review of families with a history of MSBP who had received initial intervention, both victims and perpetrators, and had been separated and then reunited. as a family. They made regular visits over several years to the family and noted the condition of the child's growth and development as well as the condition of the family. Berg and Jones (1999) provide an explanation in their research journal about 12 families with a history of MSBP where parents (especially mothers) were found guilty of committing MSBP towards their children, starting from the age of 2.5-12 years when they first experienced acts of violence. The families selected were families that had been separated before, were given counseling sessions to psychologists, underwent a doctor's review on mental health, and had been reunited between parents and children. Based on the results of the reported study, all of the victimized children were within normal limits in terms of height, weight, and head circumference at the follow-up visit. None had severe developmental delay, but 6 children did show mild delay, of which 4 were part of the "treated" group in the study. The most common obstacles in children are speech delays, language disorders, and anxiety disorders.
In their research, Berg & Jones described the condition of the mother of the perpetrator of the MSBP violence as quite disturbing when the reunification was carried out. In 1 case, during a follow-up visit, it was found that the father completely took over the custody of the child, because the mother repeated the violence against the child which resulted in bleeding and an ear infection. In other cases, it was noted that mothers who experienced relapse visited doctors during the reunification period to report illnesses that their children did not actually suffer from. Even from the initial target of 16 families that were the target of research subjects, 4 families refused to take part in the experiment because the mother's mental health condition became increasingly unstable after reunification.
Another study was also conducted by Jones and Bools (1999). They summarized one case report who had been given special psychiatric treatment for the purpose of family reunification, commenting that successful interventions usually focus on cases where parents (as perpetrators) have admitted guilt. and take responsibility for the harassment and have agreed to receive psychological treatment. The cases that are usually published are those where the intervention has been deemed successful. However, one report described less optimistic results from psychiatric interventions performed, noting that reintegration of children can cause significant psychiatric problems. This condition can be triggered by trauma caused when children experience violence and trauma when separated from their parents and reunited. The attraction of these emotions will greatly affect the emotional stability of the majority of children who are still very small where their concept of trust in the surrounding environment is still being formed, as well as causing anxiety and distrust of the people around them.
The treatment of MSBP perpetrators is indeed quite difficult because effective handling requires perpetrators to be honest. People with MSBP sometimes become so good at lying that they can no longer tell fact from fiction. If treatment is possible, generally through psychotherapy in the form of cognitive behavioral therapy can help the perpetrator to be able to accept the fact that he has done the wrong thing. The MSBP perpetrators had difficulty changing their mindset and behavior after the confrontation in the MSBP case. Experience from successful treatment will enable the offender to identify their thoughts/feelings that lead to MSBP behavior and learn to change those thought patterns. However, in general MSBP is very difficult to treat and the best solution is to remove all possible victims from the perpetrator's control (Walk & Davies, 2010). Intervention experiments on several children with a history of MSBP cases conducted by Berg and Jones (1999), showed positive results for both children as victims and parents (majority of mothers) as perpetrators, but the possibility of re-abuse was also quite high.
The good results in trials of selected case sets were attributed to the following factors: (1) recognition of the condition of MSBP itself and the context of personal mental health difficulties, parenting issues, and other psychosocial issues in which cases of MSBP occur; (2) substantial improvements in personality styles or other mental health problems and changes in family systems, which usually lead to increased openness to factual and emotional communication; (3) increase parental awareness and sensitivity to the needs of their children and realistic acceptance by offenders of the ongoing personal vulnerability they experience and take steps and actions to prevent it from recurring. When these factors appear as variables in MSBP cases that occur, the chances of success for the intervention given to both the perpetrator and the victim are also higher.
Slightly different from the research conducted by Berg & Jones, and Jones & Bools, Stirling (2007) stated that the separation of children as victims and parents must be done permanently, especially if the violence the child has received is very severe. For example, if a mother who is overly anxious and forces too much medical care on her child, is willing to work with doctors and learn when to seek care, then the child can be cared for safely in her own family environment. Conversely, if a mother repeatedly strangles her child or commits other serious acts of violence, the safest place that will guarantee the child's safety is most likely to be separated from the parents, then placing the child in the care of another family member or related social institution elsewhere permanently. Although reunification is still possible after the assessment of many parties, according to Stirling, permanent separation can be prioritized to prevent further violence in the future.
In line with Stirling's statement, Siegel & Fischer (2010) stated that a permanent separation between the victim and the immediate and distant family is urgently needed. This statement is based on the findings of their research that the poor outcomes reflect a deep reluctance on the part of courts and laws to curtail or curtail parental rights, coupled with an overreliance on the effects of psychotherapy. Children often continue to be victims while the family is being "monitored" and the perpetrator is "under the care" of those responsible. Therefore, even after the protection services unit is involved, the victim continues to be harassed because there is still the level of perpetrator contact allowed by the authorities.
Based on the explanation of the results of research conducted by Berg & Jones, Jones & Bools, and Stirling, it can be concluded that the forms of intervention that can be given to cases of violence against children must be carried out periodically and over a long period of time so that the growth and development of children as victims, parents as perpetrators, and families to succeed. With an understanding of the difficulty and complexity of handling the MSBP case itself, it is necessary to pay further attention to acts of violence against children, to see the lasting impact experienced by children as a result of the abuse they receive, especially in MSBP cases where "damage" experienced by children is not fully visible physically and psychologically, but the impact can be more severe than other forms of violence against children due to delays or inaccuracies in the form of initial treatment given.

Conclusion
In dealing with cases of violence against children such as MSBP, regular and continuous intervention is needed. The focus of the interventions carried out must aim to ensure that the child's growth and development goes well, and that the child's welfare both now and in the future can be guaranteed. Separation from parents as perpetrators is still a form of intervention needed by child victims of MSBP, however, an in-depth assessment of parents as perpetrators is still needed to ascertain whether the separation will be permanent, or reunification can be carried out. To be able to carry out separation and reunification interventions properly, relevant experts are also required to be able to better understand the forms of MSBP itself so that the application of the treatment and interventions provided can be more appropriate, especially in its application in Indonesia.
Experts must also be more observant in handling or conducting initial investigations into MSBP cases, because of the vulnerability of this action being diagnosed or classified into other crimes, or even considered not punishable by the argument of insanity (insanity). As previously explained, MSBP perpetrators are very aware of committing their crimes after conducting research or considering what steps or methods they will use to produce invisible crimes. So that the cooperation of all related parties becomes very crucial in dealing with cases of MSBP violence.