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On the "split model": so what else is new?

The split biopsychosocial model is not a problem, but rather a natural progression of the original approach over time. In this article the author compares the controversy about the model's usefulness to breast-feeding versus bottle feeding as a way of suggesting that the outcome, rather than the details of the method, is the important variable.


This article has for me a bit of the quaint air of an old controversy--such as breast-feeding versus bottle-feeding, perhaps--that seems now to be a nonevent. I am a realist, always have been and always will be. I always prefer making the best of what is possible to the frustration of tilting with windmills (Don Quixote was the ultimate idealist) and trying to uproot the deeply rooted practices of people, thoroughly and soon. I am usually quite ready to accept significant improvement or a move in the right direction, rather than hold out for the ideal and total outcome I want. I will always settle for moving in the right direction, which I think is quite a triumph a lot of the time. And I believe that we continue to move in the right direction with the presence of the biopsychosocial model, split or not.

The split model seems to me to be as obvious a good solution and move in the right direction as does mixing my preference for breast-feeding on any number of variables with the significant and vital issues of the mother's real life. Sure, I would rather see every woman breast-feed her baby, and I will always support it. But it is part of a much larger pastiche, involving many aspects of good parenting and staying sane and feeling supported and managing life, that makes it one aspect of good mothering and not worth sacrificing everything else for or making a mother feel bad about herself for.

People do what they can do. You have to hope their actions are sensitive to the right variables and moving in the right direction, but you cannot order them up to be just what you want. If the mother is bottle-feeding the baby with warmth and sensitivity, on a reasonable schedule and in a way that promotes good attachment, I am happy. If the mother is using bottle-feeding to avoid contact with the infant, or in a way that ignores the infant's needs, then we have some work to do. But that work, for me, is always about moving closer to the best format, not making that an all-or-nothing proposition. It is about keeping an ideal alive, whether or not it is optimally practiced.

I will abandon my overworked analogy. The obvious corollary is that in medicine, my goal is that the doctor is always mindful of the larger picture, of the psychosocial variables that might be at work, and trying to integrate them into care. There will be many times when he or she never gets near focusing on them until the medical variables are attended to, if at all, and I am not shocked. I do want to be sure that doctors always notice and react to the person that is the patient; that they can tell me something about that person; that they have some idea how the interaction affected the person, even if only in retrospect; and that they can imagine themselves in that person's shoes. But if all these concerns never show up in the interaction itself, and they get preoccupied with a complex (or a simple and straightforward) medical procedure and do not interact with the patient about the patient's life and context, I am not disturbed as long as this interaction can happen and does happen when it is needed.

Idealism tends to destroy useful ideas by making them all-or-none propositions. Freudian psychology is a good example: It is full of rich and penetrating insights about the human condition and has added a lot to our understanding of who we are. But psychoanalysis is nearly totally dead as a way of working with people because the idealists could not stomach anything but the pure form as being acceptable. The development of their insights and learning may well go down with the purist ship--a significant loss. Adapt or die, we realists believe, and I think we have adapted well in keeping the biopsychosocial model healthy. So the split model seems to me to be anything but a pale and inadequate compromise with the "real" biopsychosocial model; it is the form in which we have nurtured it forward, kept it alive, and helped it to be resilient and responsive to changed realities. The alternative would be to hold on for the pure form and find ourselves in a short time saying what the analysts say now: "I remember when people used to do it right--but it's all gone now."

Correspondence concerning this article should be addressed to David Waters, PhD, University of Virginia, PO Box 800729, Charlottesville, VA 229080001. E-mail:
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Title Annotation:controversy in breast feeding and bottle feeding
Author:Waters, David
Publication:Families, Systems & Health
Geographic Code:1USA
Date:Dec 22, 2005
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