Dear colleagues:

I just popped in to see what was happening on Lactnet tonight and noted the many posts about guilt and infant feeding rhetoric (i.e., risk-based versus benefit-based language). Here are a few thoughts before I have to get back to work on a publication I need to finish...

1. A propensity to feel guilt is not inherent in all cultural heritages. It requires belief in cause and effect; the power, right, and/or responsibility of an individual to enact change (in their own life and/or in the lives of others); a focus on the future, etc. Not all cultures tend to emphasize such beliefs.
2. The goal of multi-focus group research is to uncover trends at the population level so that the intervention most likely to enact the most change can be developed.
3. Among other things, the development of cultural competence is a life-long process whereby people can learn the information and skills, develop the attitudes and beliefs, and create/modify the structure and processes of institutions so that the culturally based needs of diverse groups of people can be met effectively and equitably. This process includes developing an understanding of the high applicability of research on a population to the population studied and the potentially more limited applicability of research on a population to a subpopulation, an individual within that population, a completely different population, etc. It includes developing an understanding of how culturally based beliefs may influence both a mother's evaluation of information (e.g., the particular rhetoric of a particular public health message) and her emotional responses to that evaluation.
4. The code of ethics of IBCLCs requires us to guard against cultural bias. Measuring health outcomes against the cultural norm of formula feeding (rather than the biological norm of breastfeeding) is a widespread example of cultural bias in research reports. It is an example of cultural bias because if we consider which came first in history, breastfeeding or artificial substitutes for breastfeeding, we can see that the manipulation in the experimental design is actually the use of formula, not the use of breastfeeding. It is poor science to report outcomes measured against the results of the actual manipulation.
5. Part of clinical competence is counseling competence. When we are ethically obligated to share information that may be difficult for a mother (or colleague or administrator or ...) to hear (for any reason), it behooves us to assess and attend to her evaluation of the information, and to her emotional reaction to her evaluation. It behooves us to establish whatever rapport is needed with the mother (or colleague or administrator or ...) before sharing that information so that she has some supportive emotional context in which to place that difficult information and our intent in sharing it. It behooves us to work to change our institutions' structures and processes if those structures and processes prevent us from having enough time to engage in effective counseling (and other interactions).

I think that the heatedness of discussions about guilt here on Lactnet (and elsewhere) are due, in part, to the challenge of addressing all of these issues in one intervention. Yet that is not what we are actually trying to do. We are trying to develop multiple interventions for diverse circumstances. We need interventions at the population level (hence the many focus groups of the US National Breastfeeding Awareness Campaign). We need multiple interventions for subpopulations (hence, the work of local coalitions, organizations, and agencies in their own communities). We need multiple interventions for individuals (hence, the work of individual IBCLCs, other health care providers, and peer counselors with individual breastfeeding mothers). What is effective at one level in one location at one point in history may be ineffective at another.

I think the heatedness of discussions about guilt is also due to people's deep concern about the mortality and morbidity associated with insufficient breastfeeding, their anger and frustration with the continued and widespread unethical marketing of artificial substitutes for breastfeeding, and their recognition of the importance and challenge of developing and applying cultural and counseling competence. The comments I have read in my quick visit to Lactnet tonight address different pieces of this big picture. Each perspective expressed is important and illustrative. And, each of us can play an important part in creating and implementing one or more of these multiple interventions, regardless of whether it is at the level of a population, subpopulation or individual.

I'm still nomail, so if anyone wants to reply, please carbon copy my email.

With great respect for all of you doing this hard and invaluable work,

Cynthia

Cynthia Good Mojab, MS clinical psychology, IBCLC, RLC
Ammawell
Website: http://home.comcast.net/~ammawell
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