Monthly Archives: August 2011

Accentuate the negative, eliminate the positive? The problems with Wiessinger’s ‘Watch Your Language’

Fifteen years ago, Diane Wiessinger, a breastfeeding counsellor and activist, wrote an article about breastfeeding promotion for the Journal of Human Lactation, entitled 'Watch Your Language'.  In it, she claimed to have the answer to the thorny question of why lactation consultants and the health care profession have such poor results when it comes to persuading women in the US to breastfeed.  I find this article, and the huge following it has received, to be of great concern; not only do I see no evidence for her theory, but I see a number of reasons to believe it is likely to do the cause of breastfeeding promotion far more harm than good.

Wiessinger's key premise is that, when we talk about the benefits of breastfeeding, we have it backwards.  Instead, we should talk as though breastfeeding is the norm, and frame all our discussions of the differences between the two in terms of drawbacks and harms of formula-feeding.  And we shouldn't mince words while doing so.  In Wiessinger's opinion, we should be trying to catch our flies with vinegar rather than honey, and particularly bitter vinegar at that.  For example, Wiessinger advocates telling women that 'artificial feeding results in an abnormal and unpleasant odor that reflects problems in an infant's gut', and describes formula-feeding as 'deficient, incomplete, and inferior'.  'Those are difficult words,' Wiessinger writes, 'but they have an appropriate place in our vocabulary.' 

Of course they do; however, that place is not in the speech of those wishing to describe the behaviour of those whose hearts and minds they wish to win over.

I've had a hard time writing this post, simply because I genuinely haven't known where to start – there are just so many things wrong with the article.  But I've also known that this post needs to be written.  Wiessinger's claims are hugely influential in the world of breastfeeding activism.  Google that title and Wiessinger's name, and you'll find her original article posted in its entirety in multiple places on the Net.  Lactivist website after lactivist website tells us that we should refer to breastfeeding as the norm and talk about the harms of formula-feeding instead of the benefits of breastfeeding.  I've even seen one blog describe the approach of talking about the benefits of breastfeeding as 'anti-breastfeeding'.  I think that a post pointing out the fundamental problems with this approach is long overdue and very necessary.  So, here are the many reasons why I disagree with what Wiessinger has to say.

It's counter to the evidence.  One of the principles on which behavioural psychology is extremely clear is that, if you want to change people's behaviour, the carrot is mightier than the stick.  Research in this field established decades ago that potential benefits are much better motivators for change than potential avoidance of harm.  This really is the kind of thing that gets taught in introductory psychology classes.  Which, of course, is why you don't see advertising campaigns framed around the idea that the reason you should buy product X will enable you to avoid the harms caused by going for an alternative – they're framed around the many benefits product X can offer you over the alternatives.  

Oddly enough, Wiessinger herself touches on this when she writes that the phrasing of lactation consultants pushing breastfeeding 'could just as easily have come from a commercial baby milk pamphlet'… and then comes to the rather bizarre conclusion that '[w]hen our phrasing and that of the baby milk industry are interchangeable, one of us is going about it wrong'.  Logically, if two groups of people are going about something the same way, they're either both right or both wrong.  If companies with millions to spend on employing the best advertisers are taking the approach of advertising their product's benefits, shouldn't we be considering the likelihood that they're doing this because they know it to be the most effective way of convincing people?

Yet Wiessinger shows an astonishing disregard for what the evidence in psychological research has to say.  And, given that she gives nothing to back up her opinions on this point, isn't the most likely conclusion that the psychologists all have it right and Wiessinger has it wrong?

Most people aren't that masochistic.  People generally just aren't that keen to listen to criticism.  Think for a minute about how Wiessinger's words might sound to a woman who's happily formula-fed her first child and is now expecting another.  Talk to her about the benefits of breastfeeding, and maybe she'll be open to listening and perhaps having a shot at another way of doing things.  Tell her how deficient, incomplete, and inferior her way of feeding her first child was – letting her know, while you're at it, that you think her precious adorable first baby actually stank – and something tells me that she's not going to be all that thrilled about listening to anything else you have to say.   Harshness only alienates those whom we're hoping to reach.

Of course, I'm guessing (and hoping) that most advocates of Wiessinger's approach would have enough tact to temper their words in that kind of face-to-face situation.  But the words and actions of one part of a movement reflect on the whole, especially when the words come from those speaking on behalf of the breastfeeding movement.  If the voice of breastfeeding advocacy is telling women how awful formula-feeding is, a lot of women are going to expect – and fear – the same thing from individual breastfeeding counsellors.  And that's going to put off that woman who's formula-fed a previous child or children, or the woman who's currently struggling to breastfeed but has found herself giving a few bottles of formula to get through the difficulties and is scared of what reaction she might get if she tries asking a breastfeeding counsellor for help (and, anecdotally, I've read stories from women who were put off asking for help with breastfeeding for precisely this reason), or even the woman with no previous experience who might have been willing to give breastfeeding a go but is too scared of how she might get harangued if it doesn't work out.  Adopting Wiessinger's attitude to formula will make us look horribly unapproachable to a large segment of the women we most want to have approach us.

It fails to connect with people.  When Wiessinger talks about breastfeeding being the biological norm, she ignores the fact that, for many women, it isn't the social norm.  Talking to these women as if breastfeeding was the norm isn't starting where they are.   When you start by ignoring someone's own reality and life experiences in favour of focusing on where you want them to be, or think they really ought to be, you're setting your advocacy attempt up for failure.  If you're not starting where they are, you're making it far harder to form the connection you need to form with them in order for advocacy to be effective.

The stress it causes may be counterproductive.  This is actually a point that hadn't occurred to me, but that another blogger pointed out when we were discussing this online once.  She felt that Wiessinger's approach would have been more stressful to her when trying to get lactation established, and that that stress itself might have done more harm than good by interfering with her milk production.  It's a fair point – we do know that stress can affect milk production.  While there's no way to eliminate all stress from breastfeeding initiation in all cases, we can at least do our best to avoid making matters worse by not making women who need to give some formula while getting breastfeeding going feel attacked for doing so.

It encourages an all-or-nothing attitude.  And this can also be counterproductive, by putting off women who might be willing to consider short-term feeding or mixed feeding or even breastfeeding with the occasional bottle given now and again, but who just can't see themselves wanting to aim for the current gold standard of 'breastfeed for at least a year with nothing but breastfeeding for at least six months'.  How often do you hear 'Because I wanted someone else to be able to give a bottle sometimes when I went out' given by a mother as a reason for her choice not to breastfeed?  How many more of these women might actually end up giving breastfeeding a try if they knew that it is perfectly possible to breastfeed and yet have somebody else give your baby a bottle when you go out?  Or that, if full breastfeeding is not an option, mixed feeding carries most of the same benefits as breastfeeding and is still worth considering?  It's easy enough to introduce those ideas in a context of discussing the benefits of breastfeeding.  But how do we reconcile descriptions of formula as harmful and risky with the explanation that, in fact, it doesn't appear to be a problem (despite some lactivist claims) to give a bottle of it to a fully breastfed baby now and again?  We probably don't, is the answer – and that means yet another group of women we've barred ourselves from reaching.

So, with all these problems, why has Wiessinger's approach been so popular?

When I told my husband about the article, he nodded gravely and commented 'Some people just aren't happy unless they're being unkind to other people.'  Sadly, I think there's some truth to that – there's a nasty little satisfaction that comes from believing you've got a really good excuse to say unpleasant things to people, and I think that, on that subconscious level we don't like to admit to, that may be part of the attraction for at least some of the people who espouse this philosophy.  However, I really don't think that's the whole story, and my guess would be that most of the people who believe this actually have much kinder motivations. 

I think that a bigger reason is that, when you're faced with a thorny and seemingly insoluble problem and someone who gives every indication of knowing what they're talking about comes along and tells you, in authoritative tones, that XYZ is the answer, it's pretty natural to believe them – especially when some of what they say is demonstrably true.  And, of course, Wiessinger makes a few good points in amongst the frighteningly bad ones.  Promoting breastfeeding by talking in the kind of fluffy superlatives better suited to cloud-cuckoo land isn't that great a way of reaching women, either, and it's easy for Wiessinger to convince people that the issue with that approach is the positive framing.  It's true that making breastfeeding sound like something special makes it feel out of many women's reach. (Although, oddly, by the end of the article Wiessinger seems to be taking the same approach herself.  Apparently, we should be advising women that they shouldn't merely breastfeed, but 'mother at the breast' and form a 'breastfeeding relationship'.  But, hey, no pressure to make it Really Special.)

But the use of positive language isn't the problem with the 'best possible start in life, special bond of breastfeeding, blah blah' approach.  The problem is partly that that way of describing is too overblown to be taken seriously (most people, quite rightly, are just not going to be convinced by the implication that the most important choice you can possibly make to get your children well launched into a fruitful life is that of how to feed them at the beginning of it), and partly that it doesn't connect with people any more than Wiessinger does.  The hypothetical lactation consultant Wiessinger quotes isn't finding out where each individual woman is and dealing with her particular concerns and beliefs.  She isn't giving women information about the differences between breast and bottle in any sort of practical, easily comprehensible way that can be used as a foundation for sound decision-making.  She isn't having a genuine discussion.  She isn't starting from where women are.  She isn't connecting.  And the answer to those flaws is not to adopt an approach that keeps those flaws and combines them with several more.  The answer is to put right those flaws.

I've already written about what I'd like to see in breastfeeding promotion.  Wiessinger's article is a prime example of what I don't want to see in breastfeeding promotion.  Let's please, please, please, forever put to bed the attitude that unpleasantness and scare tactics are the most effective ways of persuading anybody to do anything.  Let's go, instead, for an approach that's actually likely to work.



Filed under Milky milky, Sacred hamburger

World Breastfeeding Week – Only Connect

It's World Breastfeeding Week, and the theme is 'Communication'.  (More accurately, the theme is the rather peculiarly worded 'Breastfeeding – A 3D Experience', with communication being the 'third dimension' we're meant to write about, and time and place of breastfeeding support being the other two.  Which makes for an odd slogan, but you get the point.)  I started writing a long and detailed post that I've now had on my 'really need to blog about this one' list for more years than I care to think about, and I'm still hoping to get that one up fairly soon, though I may or may not manage it in time for the end of the week.  But, as I wrote, I found part of it needed to be a blog post of its own.  Here it is.

It's fair to say that, despite my strong opinions on breastfeeding promotion and how it should be done, I've had minimal direct experience.  This is because I work in a healthcare system where maternity care is midwife-led, and so I don't do the routine prenatal appointments that are where, in my view, it's best discussed.   However, in sixteen years as a doctor, I've had a whole lot of experience with health promotion in other areas.  I've had to start a lot of conversations on smoking and alcohol and diet and exercise.  I've had a lot of occasions of seeing my patient's eyes glaze over as I start to speak, which has given me plenty of opportunity to think about what kinds of approaches make that happen and how to avoid it.  Over the years, I've found my experience gradually formulating into a rule in my own mind: Start from where people are

Start from where their minds already are on a particular topic, because, otherwise, anything I have to say won't touch them.  When I've started talking out of my own viewpoint on a topic without acknowledging the very different viewpoint of the person sitting across from me, the mental image that has come to me has been of me sitting on one side of an abyss and yelling across to the person on the other side to climb over and join me.  Why on earth should they want to?  When I've found a way to climb across, meet them where they are, and see if I can look from their perspective to find a route I can point out to them, I can feel the difference in how well the consultation is going.  Of course, they may well still choose not to take this route – but they're thinking about it.  They're tuned in.  They're listening.

A more formal term for the concept would, of course, be 'connection'.  In reading about discipline and how to reach children, I've learned the importance of forming a connection with them to get the message across – which is, of course, a subject for another post, but I've realised that it works with people of any age and that this is precisely what I've been doing in my more successful consultations.  Or, to phrase it the way it was always phrased for us as trainees, find out the patient's ideas-concerns-and-expectations (and, yes, we did indeed use that phrase so often it turned into one word).  But the wording I still find myself repeating silently to myself when I hear myself rushing in with a generic health promotion speech to someone who isn't disposed to listen to it, is 'Start from where people are.  Don't start from where people aren't – start from where they are.'

How do you do that?  You find out where they are on the subject (and it may not be where you were expecting to find them).  You acknowledge where they are, and the life experience that led them to that point.  You think about how your advice might look through their eyes.  And you see if, moving to their spot and looking at the route from their perspective, you can figure out that route from there to where you want them to be.  Or to even a little bit closer to where you want them to be.

So, let's say you're a midwife or doctor seeing a woman for one of her prenatal appointments, and it's time to start talking about breastfeeding.  You have your spiel on the benefits and the how-to of breastfeeding prepared, all ready to launch into.  Now, let's say this woman comes from an area where just about everybody formula feeds.  She herself was formula-fed, all her friends have formula-fed their babies, and she doesn't know anybody who's breastfed.  She's distantly aware of breastfeeding as something that mothers in some other group that she doesn't belong to or identify with (middle-class women, maybe, or tree-hugging hippies, or just some undefined group in the Not Us category) sometimes do, but that no more impacts on her own life plans than the knowledge that some people go off and live on boats.  What's going to happen when you launch into your generic spiel?  It won't touch her, because there isn't any point of experience in her life that it can stick on.  It'll whistle past or over her and leave her unaffected.

But if you explore her feelings with a few questions – such as "How were you planning on feeding your baby?" "How did you make that decision?" "How much do you know about breastfeeding?" or whatever else seems appropriate, then you find out where she is.  You start from there.  You acknowledge it, without judgement: "So, it sounds like you've never really thought about breastfeeding," and then see if you can find a way to move a few steps closer to where she is – "What would you think of finding out a bit more about it, seeing if it's something you might be interested in?  After all, it's a lot more convenient when it works well, and it can cut down the chances of a lot of different illnesses for baby and you."  You test the waters, you see how much she's willing to take in then, and whether she might be willing to revisit the issue.  You do all this while trying to stay where she is, moving at most a step or two ahead so that you can see whether she'll move that much too.

Maybe she's somewhere worse than that as far as breastfeeding's concerned – maybe she's had a previous lousy experience and she isn't just indifferent to breastfeeding but actively hostile.  Then, you can sympathise – "Oh, boy, that sounds awful!  I can understand you not being too thrilled with the thought of trying again" and see if you can move forward at all from there in terms of opening up the possibility that her experience with feeding a different child might be different again.  Or maybe she's someone who's potentially interested in breastfeeding, but has some specific reason for not wanting to do it.  If you take the time to find out what that reason is and to acknowledge its validity, maybe you can figure out a compromise she'll be willing to try – breastfeeding for X amount of time, mixed feeding, breastfeeding with occasional supplements.

But always, always, aim to start from where she is.  Because, if you do that… you've got a hell of a lot more chance that she'll be willing to move over to where you are.

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Filed under Milky milky, The doctor is OUT. To lunch.