A call for ethical breastfeeding medicine education based on best available science (without ideological exclusions)
Cumulative collective knowledge (or collective intelligence) is our human genius, necessary and protective
"All flourishing is mutual." Robin Wall Kimmerer
Humans are social creatures, hardwired to want to belong. Our extraordinary capacity for social communication, collective creativity, and nurturance of each other's flourishing is why we have broken free of the bounds of mutation-based evolution, so that Homo sapiens is now a species which, extraordinarily, drives the evolution of life on this planet, shaping the future of the Earth and all other species. We are staggeringly socially brilliant.
There are many dangers and vulnerabilities to our highly social, collective human brain, however, which each us and our society as a whole needs to learn to manage if we are to continue to enhance the evolution of life - rather than destroy ourselves along with the thousands of extincting species. One of the dangers which arises out of our collective strength can be referred to as groupthink.
As health professionals, a certain kind of collective consensus within our professional organisations is necessary and protective, ensuring that standards of practice are adhered to.
How does collective consensus operate positively in the field of clinical breastfeeding and lactation support? Most of us as health professionals don’t have the bandwidth, given our personal and professional responsibilities and proclivities, to pour in the time that is required to think critically about dozens of topics relevant to our breastfeeding practice as women, or about our clinical practice as breastfeeding support professionals, let alone to seriously engage research papers.
Most of us as individual health professionals also don't have the training or skills to critically analyse research papers and to understand the serious implications of methodological weakness, nor how to keep this in perspective as we apply implementation science and build up clinical methods and protocols.
Instead, we listen to others in our professional group, we learn from them, and we cherish the very human comfort of belonging. As breastfeeding support professionals, our position is reinforced by multiple conferences, and the hundreds of thousands of conversations with colleagues that occur in a professional life-time. Not to mention social media!
Groupthink is a dangerous exclusion of those who have different views
Finally, though, we might reach a dangerous situation where it is impossible to think critically about a certain topic because so many of our colleagues believe in the dominant approach - and believe it in such incredible, elaborate detail (even if this detail lacks any kind of robust evidence-base)! This is known as groupthink.
A groupthink is a psychological phenomenon that occurs when the desire to belong within a group of people results in dysfunctional decision-making. Groupthink requires active suppression of dissenting viewpoints, and in healthcare, can result in what has been called ‘the medical miracles delusion.’ We could extend this term to also refer to 'the paramedical miracles delusion'.
When groupthink is active, those who dissent intellectually aren't invited in for robust discussion and debate. Instead, (as occurs, for example, in the world of breastfeeding and lactation support), they are excluded or denigrated or their incomes are put at risk or even destroyed, through blogs and private social media posts questioning their competence, experience, or professionalism; withdrawal of rights to attribute continuing professional development points to their educational offerings; the compilation of online preferred provider lists, labelling those not on these lists as uninformed or incompetent; and through various other mechanisms.
In groupthink, expulsion of contradictory perspectives is necessary to preserve the group identity and coherence. Groupthink becomes dangerous because it is not being managed consciously by the group's professional organisations. Groupthink shuts down innovation and dissent. In an age of social media, this rejection of critical thinking within clinical breastfeeding and lactation support networks can be brutally uninformed, but is propagated both by the unconscious need to belong and the conscious need to protect one's own financial survival in the business world of community-based lactation support clinical and educational practice!
For example, for many years now, lists have been circulated of lactation consultants, oral surgery providers, and other health professionals who are ‘tongue-tie informed’ or 'ankylofrenula-informed'. In closed social media or other online groups, without regulation or fact-checking, those speaking out critically are defamed.
Recently, I listened in to speakers featured in an international conference for lactation consultants and other breastfeeding support professionals. A wide range of breastfeeding problems were attributed to oral connective tissue and fascial tightness. There appear to be very few breastfeeding problems that these presenters don't view as possibly arising from oral connective tissue tightness!
The speakers referred to evidence-based practice and research a great deal, and stressed the need for conservative interventions first – claiming that frenotomy should be considered only when conservative interventions (fit and hold work, bodywork) failed. But listening to these speakers was disheartening because the standard fit and hold and bodywork approaches explored in detail in their presentations often don't help breastfeeding women and their babies. That is demonstrated in existing research. Their models of the biomechanics of infant suck in breastfeeding were inaccurate.
Why funding for methodologically strong research in clinical breastfeeding and lactation support is urgently required
The passage of time helps. The expectation of positive results helps, with a powerful and measurable impact on both the mother’s and her health professional’s assessment of the situation. This is known as the neurobiological power of expectation. A kind and caring therapeutic intervention helps, because of the validation and psychological support.
When parents are investing money into an intervention, the positive neurobiological impact of expectation is known to be even higher. This is why high quality research aims to set up randomised controlled trials which compare an intervention group with standard treatment or no treatment group, to make sure that the passage of time, or the neurobiological effects of expectation, are not the cause of any changes observed.
I grieve sometimes because of the powerful group think that has taken hold in the field of clinical breastfeeding and lactation support during my life-time, across thousands or even hundreds of thousands of health professionals and others who work with mothers and babies worldwide, at least in high income countries. This impacts very powerfully on the lived experience of breastfeeding women and their babies, hour by hour by hour, day by day. No wonder that, despite a great deal of talk about using a conservative approach first, the rates of frenotomy continue to increase exponentially, and traditional bodywork therapy is now increasingly dominant in clinical breastfeeding and lactation support, despite lack of methodologically reliable evidence to support it.
Ideology and groupthink offer comfort and belonging in a complex world - but are divisive and unkind
There is something primal about an older or more experienced woman’s desire to protect new mothers’ heroic efforts to breastfeed their young. But in the subculture (you might even call it an underworld, given that this world remains hidden until you suddenly find yourself in it) of breastfeeding women and their supporters, this can at times take the form of a somewhat authoritarian certainty, a righteous conviction that there are ways in which things should be done.
This tone of righteous authority, which has been widely adopted in breastfeeding circles throughout my lifetime, to my mind rivals the tone of unconscious patriarchal righteousness often critiqued by feminists - although of course both are in the end simply a compensation for fragility around worth, recognition, meaning. I have seen this righteous tone at work many times, heavy with a kind of moral superiority, in direct communications and presentations in the field of lactation medicine, in anonymous reviews of my research papers, and also in social media.
It's one of the reasons why I think the identities of all reviewers of breastfeeding and lactation research should be declared and transparent, a trend in the most credible research journals these days but not yet offered in key lactation research journals.
One senior breastfeeding medical doctor in the Academy of Breastfeeding Medicine mused, when discussing a verbal attack I'd experienced from a prominent breastfeeding medicine physician, that breastfeeding advocacy has become strident because we have not been heard for so long. It is true that there is a form of horizontal or lateral psychological or financial violence which might spread insidiously when a particular sub-group have been silenced inter-generationally. In a state of chronic anger or frustration, due to longstanding devaluing by powerful external organisations, the group turns on itself, cannabalises the ‘other’ who seems to stand outside the group but dares to claim a place within it.
But I have witnessed territorial anxieties to do with ego and identity which absolutely do intend to expel someone from the group, whether it's a desire to expel the outsider or disruptor from the capacity to be published in breastfeeding journals, or from a role in education and conference presentations, or even from having the right to have her work mentioned in a breastfeeding medicine network newsletter when other colleagues who run small clinical and education businesses are profiled. This psychological violence results in professional women leaving active participation in the fields of breastfeeding and lactation medicine, in order to protect their own wellbeing.
Instead of locating itself wisely and intelligently in the great ebb and flow of sociocultural movements, corporate contexts, and evidence-based medicine, the group loses its greater vision and becomes lost in a groupthink echo chamber, directing little or even big cuts at unfortunate outsiders. Those who dare to publicly speak out about this are inevitably labelled as divisive, angry, jaundiced, or damaged - an old trope used to dismiss the one who dares to disrupt.
It would be best for families if those who are passionate about the support of breastfeeding and lactation actively invite intellectual debate and dissent and celebrate the work of committed colleagues, even across difference
Instead, I think the breastfeeding community needs to consciously examine and start talking about the groupthink that has taken hold in the West in breastfeeding and lactation support circles.
It grieves me to hear of personal and professional damage being done to courageous individuals who dare to speak out against yet another trend to unnecessary overtreatment in the care of breastfeeding mothers and their babies. It grieved me even before I found out that the groupthink applied to me, too!
This is such a vulnerable time of life for families. Mothers and babies need their health professionals to be freely engaged in the most robust and inclusive and respectful intellectual debates possible! This is what we aim to do in Possums.
Recommended resources
'How groupthink impacts our behavior', by Chendra Kerry
Possums Breastfeeding & Lactation articles which address lactation non-profits, ideology, and harm
Selected references
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