Introduction
Breastfeeding, or lactation, is the biological norm for the human species, with breast milk providing all essential nutrients for infant growth and development. The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of an infant’s life, followed by continued breastfeeding with the introduction of solid foods for up to two years or beyond (World Health Organization, 2011). Despite this, breastfeeding rates in the UK are the lowest in the world (The Lancet, 2016). Whilst 81% of mothers initiate breastfeeding at birth, these rates drop to 34% continuing to breastfeed in some form by 6 weeks and 0.5% at 1 year (McAndrew et al., Reference McAndrew, Thompson, Fellows, Large, Speed and Renfrew2010; The Lancet, 2016).
Successful breastfeeding, according to parents’ preferred wishes, has been shown to offer a protective effect against postnatal depression (PND) (Dias and Figueiredo, Reference Dias and Figueiredo2015). However, when breastfeeding challenges arise, with inadequate support to address them, there is a significantly higher chance of developing PND (Ystrom, Reference Ystrom2012), as well as poorer attachment outcomes between mother and infant (Abuhammad and Johnson, Reference Abuhammad and Johnson2021). Qualitative research by Brown (Reference Brown2018, Reference Brown2019) has explored the area of breastfeeding trauma and grief. In her research, she found that of the women whose breastfeeding journey ended prematurely, a significant proportion experienced these endings as subjectively traumatic, reporting themes of failure, inadequacy, isolation and loss, often enduring for many years without a sense of closure or recovery (Brown, Reference Brown2018; Thomson et al., Reference Thomson, Ebisch-Burton and Flacking2015). Brown’s research (2019) also compared the women’s accounts against the DSM-5 diagnostic criteria for post-traumatic stress disorder (PTSD) (American Psychiatric Association, 2013), and identified women reporting intrusive symptoms, avoidance symptoms, negative alterations in cognitions and mood and alterations in arousal and reactivity. Particularly in relation to re-experiencing symptoms, accounts described a sense of ‘nowness’, memories being easily triggered and involuntarily, and remaining vivid and highly sensory. However, to note, it is unclear to what extent the self-reports would meet clinical thresholds of PTSD.
Black et al. (Reference Black, Sinclair, Miller, McCullough, Palmér, Slater and Tesler Stein2022) also developed a psychometric screening tool to identify breastfeeding-related post-traumatic stress disorder (BF-PTSD). While they suggest that 7% of women with a challenging breastfeeding experience have reactions which could meet the criteria for PTSD, this is based on comparison with the PTSD Checklist for DSM-5 (PCL-5) (Weathers et al., Reference Weathers, Litz, Keane, Palmieri, Marx and Schnurr2013), which is a useful but non-diagnostic self-report measure. A small number of cases of breastfeeding trauma may meet the threshold for Criterion A in DSM-5 diagnostic criteria (American Psychiatric Association, 2013), i.e. threat to life or serious injury to baby due to malnourishment, but the majority may not experience such a threat. Clearly, more research is needed in this area to assess the incidence and nature of PTSD in postnatal mothers with challenging breastfeeding experiences, and to what extent their subjective experiences of trauma overlap with diagnostic criteria.
In our clinical experience, we propose that the breastfeeding experience can be viewed as broadly traumatic, depending on the challenges faced and the specific meaning of those for the individual. Individuals may then present with a range of subsequent clinical presentations, including but not limited to depression, anxiety, adjustment-related difficulties, and, for a subset of mothers, PTSD. Some may also experience subthreshold symptoms of PTSD, e.g. limited re-experiencing, hyperarousal and avoidance symptoms, without meeting full criteria.
Of key relevance, the concept of moral injury has gained significant attention in recent years. Moral injury can be understood as perpetrating, failing to prevent, witnessing, or learning about acts that transgress an individual’s moral beliefs, which lead to psychological, emotional, behavioural, social, and/or spiritual consequences for the individual (Litz et al., Reference Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen2009). Additionally, moral injury has recently been included in the DSM-5-TR (American Psychiatric Association, 2025), and whilst not categorised as a clinical disorder or diagnosis, its inclusion as a ‘moral problem’ represents the growing recognition of the concept. Research also suggests that exposure to morally injurious events and the subsequent cognitive, emotional and behavioural responses are associated with mental health conditions, such as PTSD and depression (Williamson et al., Reference Williamson, Stevelink and Greenberg2018). Brown (Reference Brown2019) discusses reasons why breastfeeding matters so much to some women, including viewing breastfeeding as an integral part of their maternal identity. For some mothers, breastfeeding may therefore be entwined with a perceived ‘right way’ of mothering. Events that challenge or lead to early cessation of breastfeeding when strongly desired could provoke a violation of the mother’s expectations, beliefs, or moral code of being a ‘good enough mother’, and therefore be experienced as morally injurious.
Rozek and Bryan (Reference Rozek, Bryan, Currier, Drescher and Nieuwsma2021) have proposed a cognitive behavioural model of moral injury, which integrates Beck’s longitudinal cognitive model (Beck et al., Reference Beck, Rush, Shaw and Emery1979) with the cross-sectional ‘hot cross bun’ model (Greenberger and Padesky, Reference Greenberger and Padesky1995) linking cognitive, emotional, physical and behavioural responses, and stipulates the activating event as a potentially morally injurious event. Another model proposed by Barr and colleagues (Reference Barr, Atuel, Saba and Castro2022), the dual-process model, although not specific to CBT, may also help conceptualise and address moral injury.
In the authors’ clinical experience, however, the most helpful model of moral injury in CBT, relevant to breastfeeding trauma, is Murray and Ehlers’ (Reference Murray and Ehlers2021) model of moral injury in PTSD. The clear connections between elements of this model (how they influence and prevent change in one another) and the role of appraisals before, during and after the trauma are particularly helpful in co-creating the conceptualisation with clients, enabling a collaborative understanding of the development and maintenance of presenting issues and setting the path for intervention.
There is an argument that, unless evidence suggests that scientifically supported approaches and models for PTSD do not work for moral injury, we should utilise them (Currier et al., Reference Currier, Drescher, Nieuwsma, Currier, Drescher and Nieuwsma2021). Therefore, in the absence of evidence-based models for breastfeeding trauma and moral injury, and until further research has been conducted exploring the prevalence and experiences of trauma, PTSD and moral injury in women with traumatic breastfeeding experiences, drawing on Murray and Ehlers’ (Reference Murray and Ehlers2021) moral injury model may be useful. It is likely to be particularly useful for the subset of women whose potentially morally injurious event(s) is in line with the DSM-5 diagnostic criteria for PTSD (American Psychiatric Association, 2013).
To date, no therapeutic conceptualisation for understanding breastfeeding trauma or associated distress has been proposed. In this paper, we draw from Murray and Ehlers’ (Reference Murray and Ehlers2021) cognitive model for moral injury in PTSD to present a cognitive formulation of breastfeeding trauma. Particular consideration is given to (1) the role of pre-existing and maintenance appraisals related to feeding experiences and (2) contextual factors relevant to the breastfeeding mother at various stages of the conceptualisation. A hypothesised case study with a simplified formulation and treatment practice guidelines is also discussed, based on trauma-focused cognitive behavioural therapy (TF-CBT). Finally, the applicability of the conceptualisation and potential areas for further research are discussed.
For this paper, the terms ‘mother’ and ‘breastfeeding’ have been used, given that these are the predominant terms used for individuals experiencing this form of trauma. However, the discussion acknowledges gender identification and other forms of lactation.
Proposed cognitive formulation for breastfeeding trauma
Core tenets of the original Ehlers and Clark (Reference Ehlers and Clark2000) cognitive model of PTSD include (1) the client’s perception of sense of threat and emotional symptomatology are influenced by negative appraisals of the event, in the context of their individualised world view, (2) the trauma memory is poorly elaborated and processed in a predominantly sensory way, and (3) the client’s cognitive and behavioural coping strategies inadvertently lead to the maintenance of their sense of threat and symptomatology. In addition, the adapted model of moral injury (Murray and Ehlers, Reference Murray and Ehlers2021) recognises other negative emotions, such as guilt, shame, and anger, stemming from acts of omission or commission by the individual and/or a sense of betrayal by others.
Figure 1 presents a proposed cognitive formulation for understanding breastfeeding trauma, based on the cognitive model for moral injury in PTSD (Murray and Ehlers, Reference Murray and Ehlers2021). Of note, adaptations to headings have been made to reflect the specific presentation. Firstly, prior experiences and beliefs have been separated into two areas: those in the prenatal period (prior to pregnancy) and those in the perinatal period (pregnancy, birth and up to two years post-partum). Secondly, characteristics of the trauma event have been made specific to the feeding experience. Thirdly, there is a heavy emphasis on the negative appraisals of the event and related metacognitions.
A proposed conceptualisation of moral injury from breastfeeding trauma, based on the cognitive model of moral injury in PTSD (Murray and Ehlers, Reference Murray and Ehlers2021).
Prior life experiences and beliefs
Prenatal experiences
Prior beliefs about breastfeeding may develop long before a child’s birth, shaped by familial history and beliefs, cultural norms, media representations, peer socialisation, and personal hopes and expectations for parenthood. For example, an individual growing up in a household where breastfeeding is observed and encouraged openly may develop beliefs such as ‘this is the normal way that babies are fed’. These beliefs may then be further reinforced by the norms of the society they live in and by the feeding experiences they observe in peers raising children. This model suggests that for mothers who do not hold strong prior beliefs and expectations on breastfeeding, there may be greater flexibility in appraisals when feeding experiences do not go to plan. However, for those whose sense of identity in parenthood may have been shaped and entwined with a moral code to breastfeed, the impact of a negative breastfeeding experience may more likely lead to excessively negative appraisals.
Perinatal experiences
Antenatal narratives can also shape prior views on breastfeeding. In the UK, the health and well-being benefits of breastfeeding are primarily promoted during antenatal care, supported by NICE guidelines (2021) and underpinned by UNICEF’s Baby Friendly Initiative (UNICEF, 2021). As a result, there is often a lack of education about formula feeding.
Birth experiences are influential factors in breastfeeding initiation, with studies reporting increased breastfeeding challenges following Caesarean birth (e.g. Chen et al., Reference Chen, Yan, Gao, Xiang, He, Zeng, Liu, Sha and Li2018; Sorkhani et al., Reference Sorkhani, Namazian, Komsari and Arab2021). In addition, significant postpartum blood loss (Thompson et al., Reference Thompson, Heal, Roberts and Ellwood2010), drug medications utilised during birth (Hemati et al., Reference Hemati, Abdollahi, Broumand, Delaram, Namnabati and Kiani2018; Lind et al., Reference Lind, Perrine and Li2014), premature birth (Zukova et al., Reference Zukova, Krumina and Buceniece2020) and subsequent early separation of mother and baby (Gianni et al., Reference Gianni, Bezze, Sannino, Baranello, Roggero, Muscolo, Plevani, Moro and Mosca2018) can all affect breastfeeding initiation. The physical impact and psychological stressors associated with these experiences can negatively affect the production of the mother’s milk supply and the opportunity to establish breastfeeding immediately after birth, known as the ‘golden hour’ (International Federation of Gynecology and Obstetrics, 2023).
Beliefs established following birth, including those related to birth trauma, may further influence the way in which the feeding experience is conceptualised. For example, a negative birth experience can lead some women to be more determined to breastfeed, as a form of ‘healing’, to address perceptions of failure of their body to ‘do the right thing’ and to offer a reparative experience (Brown, Reference Brown2019; Wheeler et al., Reference Wheeler, Sweeting, Mayers, Brown and Farrington2025). In doing so, this can have a protective or mitigating impact on their mental health (Wheeler et al., Reference Wheeler, Sweeting, Mayers, Brown and Farrington2025).
Characteristics of traumatic feeding experience and trauma consequences
Given the WHO recommendation for exclusive breastfeeding for the first six months (World Health Organization, 2011), this period post-partum is particularly relevant for the breastfeeding individual. Establishing breastfeeding may be challenging for new mothers for several reasons. There may be issues with the mother’s milk supply, particularly if recovering from a traumatic birth or if opportunities to initiate feeding are challenged, as discussed above. Additionally, the baby may struggle to latch onto the breast to receive milk and stimulate milk production, e.g. due to an anatomical challenge such as a tongue-tie (Tomara et al., Reference Tomara, Dagla, Antoniou and Iatrakis2023). Maintaining breastfeeding, even once initiated, may therefore be challenging.
As a result, several consequences may occur. Babies may require additional interventions, such as ongoing monitoring of weight gain, referral for paediatric support, and encouragement of formula supplementation and hand- or pump-expressed milk. In relation to the baby’s health, a medical term commonly used to describe babies who are not gaining weight or progressing as expected is ‘failure to thrive’ (Homan, Reference Homan2016). This term can feel emotionally charged where breastfeeding has not gone as hoped or expected, and thus contributes to feelings of guilt, inadequacy and helplessness (Thomlinson, Reference Thomlinson2002). Collectively, the feeding experience and consequences can therefore directly transgress the mother’s expectations of breastfeeding.
In addition, mothers may find they are faced with a lack of support from postnatal services in establishing or maintaining breastfeeding, despite breastfeeding promotion antenatally. Lack of funding and closures of breastfeeding support services are common (Better Breastfeeding, 2018; UNICEF, 2017). General Practitioners with less specialist knowledge in infant feeding may suggest supplementation with formula milk, despite this not being supported by NICE guidelines (National Institute for Health and Care Excellence, 2021). This can lead to a vicious cycle of reduced milk production and increased reliance on formula milk.
Messaging from the extended social network (including health professionals, family, friends, parenting peers, social media) may minimise the importance of breastfeeding to the mother, e.g. ‘It does not matter if you cannot breastfeed, as long as the baby is healthy’ and lead to the individual suppressing or disregarding their own feelings. Finally, the breastfeeding experience may differ from that of those in proximity to the individual, e.g. others in an antenatal group, which may impact their reactions and sense of ‘difference’.
Cognitive processing during feeding experiences
According to the Ehlers and Clark (Reference Ehlers and Clark2000) model, how an individual processes an experience at the time it occurs influences the integration of the memory and the meaning attributed to the experience. During a traumatic experience, sensory processing can dominate over executive-guided processing and emotional dissociation, that is, numbing of emotions and detaching from the experience, may occur to help cope with overwhelm. However, such cognitive processing can interfere with the formation of a coherent memory (Foa and Hearst-Ikeda, Reference Foa, Hearst-Ikeda, Michelson and Ray1996), putting the individual at risk of developing post-traumatic stress (Ehlers et al., Reference Ehlers, Clark, Dunmore, Jaycox, Meadows and Foa1998). Individuals can even experience ‘mental defeat’, characterised by a perceived loss of autonomy and sometimes a sense of no longer being human (Ehlers et al., Reference Ehlers, Maercker and Boos2000). Additionally, the mother’s cognitive processing of feeding experiences may be affected by factors such as sleep deprivation and exhaustion, post-partum hormonal changes, and structural and functional brain changes (Hoekzema et al., Reference Hoekzema, Barba-Müller, Pozzobon, Picado, Lucco, García-García, Soliva, Tobeña, Desco, Crone, Ballesteros, Carmona and Vilarroya2017; Orchard et al., Reference Orchard, Rutherford, Holmes and Jamadar2023). Finally, health issues and medical treatments such as blood loss and medication, highlighted in the ‘Perinatal experience’ section, may also affect cognitive processing during feeding experiences in the early recovery stages post-birth.
Nature of traumatic feeding memories
Ehlers and Clark’s model (2000) suggests that traumatic experiences are processed in such a way that they are poorly integrated into memory, emotionally charged, and experienced with a ‘here and now’ quality, rather than an autobiographical ‘distanced’ narrative. The act of breastfeeding is sensory on multiple levels, including physical (baby latching on to the breast, suckling against breast rhythmically, sensation of the milk ejection reflex known as ‘let down’, skin-to-skin contact), visual (profile of baby at the breast), auditory (sound of baby drinking) and olfactory (smell of baby, smell of the milk). This model hypothesises that when breastfeeding memories are experienced as traumatic, these experiences leave rich sensory impressions which are later easily triggered.
Negative appraisals of the traumatic experiences and their effects
Individuals may experience excessively negative beliefs related to their perceived role and responsibility for breastfeeding not going as hoped (perpetration-based moral injury), e.g. ‘I am starving my baby’, ‘I am failing my child’ and failure to prevent the introduction of alternative forms of feeding (acts of omission), e.g. ‘Giving them formula is like giving them poison – it is wrong and disgusting’ and ‘I should have worked harder to stop formula being introduced’. Individuals may also experience shame and guilt-based cognitions related to their own desire to breastfeed, aside from the benefits to the child, e.g. ‘I am selfish for wanting this to work’ and fears for the implications for future attachment with the baby, e.g. ‘If I cannot make this work, we [mother and baby] will not bond’. At the time of the experiences, individuals may be left feeling betrayed by others, e.g. ‘Nobody is helping me’.
Common cognitive themes in the aftermath of the feeding experiences may include a sense of failure, e.g. ‘My body failed me’, ‘I did not do what I was biologically programmed to do’ and ‘I have failed as a mother’, linked to prior formed world views and particularly when comparing with others in the postnatal period. In addition, themes associated with anxiety around the consequences to the baby’s health, e.g. ‘My baby missed out on the health benefits they needed’, and loss for the mother, e.g. ‘I will never have that experience’. Finally, in terms of a lasting sense of betrayal by others, mothers may have cognitions such as, ‘Health professionals let me down’ and ‘They told me breastfeeding would be natural and easy – they sold me a lie’.
Ehlers and Clark’s (Reference Ehlers and Clark2000) model also recognises the role of metacognitions in maintaining the ongoing sense of threat and emotional reactions. Metacognitions may involve minimising and denial of emotional reactions, e.g. ‘I should stop feeling this way’, ‘I should be grateful my baby is healthy’ and response to invalidation or lack of understanding from others, e.g. ‘No one understands this, no one gets it. I must be the problem’.
Sense of threat and emotional reactions
For women who experience a traumatic stress reaction, symptoms may include intrusive and distressing memories related to feeding, e.g. images and sounds of a baby in distress from hunger, or physical sensations in the breast whilst expressing milk. Such intrusions may occur at night in the form of night terrors or nightmares, with a threat focus towards the baby and/or mother. Changes in cognitions and mood may also include feelings of sadness, anxiety, helplessness, guilt, shame, anger, resentment, loss and grief. Increased hyperarousal may manifest as irritability and poor concentration.
Matching triggers
The traumatic feeding memories lead to a sense of threat and high emotional reactions via triggers which match, or are similar to, sensory cues experienced at the time of the trauma. In the case of breastfeeding trauma, some triggers may be more overt and clearly connected to the experiences, e.g. visual triggers of seeing others breastfeeding or seeing formula milk tins in the supermarket, or audio triggers of hearing newborn babies crying. Future medical appointments related to the baby’s health, e.g. GP, health visitor, or paediatric appointments, may also trigger emotional reactions. Given the sensory nature of breastfeeding, so too can the triggers be sensory in nature and match those at the time of the traumatic feeding experiences, and can cause the so-called ‘affect without recollection’ (Ehlers and Clark, Reference Ehlers and Clark2000). Although subtle and uniquely individual to each person’s experience, triggers to consider may include the smell of fresh or stale formula or breast milk, skin-to-skin contact with baby, sensations or pain in the breast, and postures of holding baby in a cradle or other common feeding positions.
Cognitive and behavioural maintenance strategies
The model describes how adopting cognitive and behavioural strategies to cope may reduce unpleasant feelings in the short term but may inadvertently maintain, and even increase, symptoms in the long term. This is achieved by directly producing further threat and emotional reactions, preventing change in negative appraisals, and/or preventing the opportunity to update and elaborate on the nature of the traumatic feeding memories.
Avoidance is a key strategy adopted to escape the emotional pain induced by internal and external reminders. This can be behavioural (e.g. withdrawal from others and avoidance of situations where breastfeeding might be encountered), cognitive (e.g. thought suppression), and emotional (e.g. emotional suppression and numbing).
Rumination over feeding experiences and playing out ‘what if’ scenarios may also be common, as may unhelpful thinking styles such as ‘compare and despair’ and ‘all or nothing thinking’, leading to further feelings of guilt, shame and anger. Hypervigilance towards the baby’s health may lead to excessive monitoring behaviours, e.g. frequent weight checking. Safety-seeking behaviours, such as seeking out bottle-feeding mothers in baby groups or making short trips out to avoid feeding in public, may also be common. More subtly, mothers may develop a pre-prepared narrative to counter any questions around their feeding journey.
Self-punishment behaviours may include self-harm, alcohol and substance misuse, and further maintain the poorly integrated memory, sense of threat and negative appraisals. The impact of these feeding experiences may influence longer-term decision-making, such as planning future pregnancies, or pre-occupation with breastfeeding reparation for these.
An illustrative case study of breastfeeding trauma
The authors present a composite clinical vignette, based on clinical and personal experiences, to illustrate the proposed conceptualisation.
Case description
Alyssa is a woman in her mid-thirties who became a parent to Raya 6 months ago. Prior to Raya’s birth, Alyssa had experienced two previous pregnancy losses. Alyssa very much wanted a baby and wanted to embrace what she perceived to be ‘fully natural motherhood’, that is, she was keen to experience a vaginal birth and breastfeed her child.
Alyssa’s labour with Raya ended in an emergency Caesarean section due to foetal distress. Raya latched on successfully to breastfeed in the hospital, but struggled to latch when they were discharged. Raya was placed on a feeding plan, in which Alyssa had to pump milk, feed Raya from the breast every 2–3 hours, and then top up with the expressed milk in a bottle. She found the experience painful, felt exhausted and anxious, and found it challenging to access follow-up breastfeeding support. She reported key experiences of being alone in the middle of the night, when Raya was crying and struggling to latch. She was scared that her baby was starving and that she couldn’t feed her. She reported feeling helpless, overwhelmed, rejected and ‘a failure’ as a mum. There were two key events where she remembers these experiences very intensely, but there were several other less acute experiences which were similar in nature over a 3-week period.
Although Alyssa’s mother and sister were supportive in practical ways post-birth, neither of them breastfed their children, and they struggled to understand Alyssa’s desire to breastfeed. They were concerned for Alyssa’s well-being, encouraging her to have some separation from Raya and to consider switching to formula feeding. Over the following 10 days, Alyssa switched to fully formula feeding. Although she felt some relief that Raya was more settled and gaining weight, she felt guilty and believed that the formula was not as nutritious as her breast milk. She would often cry through feeds and disconnect from the experience, feeling an intense sense of loss that this was not what she wanted, and thinking she would not be as bonded to her baby without breastfeeding.
Alyssa was referred for perinatal mental health support through her local Talking Therapies service, following an appointment with the health visitor. During the appointment, Alyssa disclosed feeling low, helpless, struggling to sleep due to ruminating about breastfeeding ‘going wrong’, intrusive images and physical sensations related to breastfeeding, and feeling anxious when attending baby groups. She was seeking help because Raya was about to start weaning onto solid foods, and she was worried she might not eat or get enough nutrients. Triggers for Alyssa included skin-to-skin contact and her daughter crying for long periods. During these triggers, Alyssa would feel an intense sense of anxiety and helplessness and reported that she felt like she was back in the room at night when she struggled to breastfeed. She reported she could feel the weight of holding her as a baby, sensations in her breasts associated with breastfeeding, would see flashes of the room being dark and hear the sound of her daughter as a baby crying uncontrollably. She reported believing Raya was genuinely starving at these times and that she couldn’t do anything to help her. These beliefs and intrusive symptoms persisted, in spite of evidence from the health visitor that Raya was thriving and healthy.
Assessment
During the initial assessment, the above case information was elicited, focus was placed on establishing a sense of safety within the therapeutic relationship, and outcome measures were completed. These assessed postnatal depression, anxiety, post-traumatic stress symptoms, breastfeeding experience, post-partum bonding and ratings around Alyssa’s hopes and goals for therapy. A presentation of postnatal depression was considered, with breastfeeding difficulties being considered a critical incident (Beck, Reference Beck1967) and cognitions related to a sense of failure. However, this formulation struggled to incorporate the current sense of threat and re-experiencing symptoms that Alyssa would experience during triggers. Despite evidence that her daughter was thriving, the feelings of helplessness and belief that she was starving persisted in response to matching triggers rather than generalised to other elements of parenting.
The use of the Patient Health Questionnaire- 9 (PHQ-9; Kroenke et al., Reference Kroenke, Spitzer and Williams2001) and PCL-5 (Weathers et al., Reference Weathers, Litz, Keane, Palmieri, Marx and Schnurr2013) identified significant symptoms of depression and PTSD, including re-experiencing symptoms linked to specific memories. The Generalised Anxiety Disorder-7 (GAD-7; Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006) score suggested moderate anxiety and worry.
In this case, the symptoms of depression appeared secondary to the trauma and were a reflection of Alyssa’s ongoing sense of failure, guilt and rumination on the outcome of her breastfeeding journey, conceptualised as post-traumatic cognitions. The anxiety was related to a current sense of threat and her fear that her baby would starve if she didn’t eat, rather than more generalised anxiety.
Treatment
Formulation and psychoeducation
Alyssa and her clinician collaboratively developed a client-friendly, simplified formulation using our proposed breastfeeding trauma conceptualisation. This helped Alyssa understand the origins of her distress and the processes that were maintaining it. Figure 2 represents the initial co-created formulation, which was revisited and amended over the course of therapy. The formulation included points of intervention, enabling it to serve as a meaningful map for therapy and guide treatment planning, and to instil hope in Alyssa.
An example formulation for client Alyssa.
Psychoeducation around breastfeeding trauma, PTSD and moral injury was shared with Alyssa. She agreed as a homework task to read a chapter a week of Amy Brown’s (Reference Brown2019) book, ‘Why Breastfeeding Grief and Trauma Matter’, and identify information, thoughts and feelings which resonated with her, as a way of normalising her feelings.
Reliving and updating appraisals
The clinician supported Alyssa in reliving one of her distressing breastfeeding memories through eyes-closed re-imagining. She identified key intrusive hotspots, which included an image of her trying to express milk with none coming out and the auditory sound of Raya crying. She recalled peri-traumatic appraisals which included ‘She is going to starve if I cannot get this milk out’ and ‘I am a failure’ and post-traumatic appraisals related to breastfeeding ending prematurely for her, including ‘She has lost all the health benefits she deserved’, ‘I will never be close to her now’ and ‘No-one helped me, they all let me down’.
The clinician worked with Alyssa to challenge some of the unhelpful thoughts, based on CBT approaches, by updating them with knowledge of what she knows now, e.g. Raya is a happy and healthy baby, based on evidence from her behaviour and feedback from health appointments, and utilised these updates for further reliving with cognitive restructuring. Alyssa and her therapist reviewed her breastfeeding journey with compassion, focusing on the effort she had put into breastfeeding and expressing milk for her daughter, and the biological benefits this had given her in her first days after birth.
Cognitions related to her sense of betrayal and being let down by services were explored, validated and considered from a wider systemic lens, e.g. under-resourcing in health services. Imagery rescripting approaches were also used to adapt and update the traumatic images and to foster self-compassion for Alyssa in the moment, e.g. by bringing in a compassionate other to provide her with the support, nurturance, and understanding she needed at the time. Physical updates included Alyssa placing a hand on her chest during reliving to note the absence of a breast pump in the here and now.
Trigger discrimination
Alyssa identified reminders that triggered her intrusive memories and associated distress in the present day. These included hearing Raya cry, skin-to-skin cuddles with her, seeing other people breastfeeding, and noises that reminded her of the breast pump. Using a trigger discrimination approach (Ehlers et al., Reference Ehlers, Clark, Hackmann, McManus and Fennell2005), Alyssa’s clinician supported her in identifying the key differences between the reminder in the past and in the here and now. For example, with the sound of Raya crying, Alyssa was able to distinguish the differences in pitch and intensity of the cry in the newborn weeks from the cry of her current 6-month-old, as well as identifying the different contexts of the cry, e.g. ‘as a newborn she was hungry, as a 6-month-old she wants her favourite toy’. This included the cognitive update that Alyssa is now able to comfort and soothe her baby in ways other than breastfeeding her.
To address the trigger of skin-to-skin cuddling, Alyssa developed a plan with the clinician to initially wear a crop top to cover her breasts and hold the baby higher on her chest, so they were cheek-to-cheek. This allowed skin-to-skin contact without contact on her chest. She would also hold Raya facing away from her, so that the position felt different. Gradually, as she started to tolerate and enjoy these cuddles more, she was able to progress to cuddling her baby face-to-face and noticed an increased sense of connection to Raya during these periods. Skin-to-skin contact has been shown to boost oxytocin in both mother and child, which in turn can support attachment (Moore et al., Reference Moore, Bergman, Anderson and Medley2016; Moore et al., Reference Moore, Brimdyr, Blair, Jonas, Lilliesköld, Svensson, Ahmed, Bastarache, Crenshaw, Giugliani, Grady, Zakarija-Grkovic, Haider, Hill, Kagawa, Mbalinda, Stevens, Takahashi and Cadwell2025). Seeing her baby content in these moments allowed Alyssa to update her belief that her daughter was rejecting her and see that they were now closely bonded.
Addressing avoidance and maintenance behaviours
Alyssa and the clinician developed behavioural experiments to attend baby groups and test out cognitions such as ‘People will judge me for bottle feeding’. She identified potential challenges with the clinician, such as seeing breastfeeding mothers and identifying how she would know if people were judging her. They discussed helpful statements she could say to herself in these scenarios, e.g. ‘Everyone’s journey is different’ and ‘I can be sad to see others breastfeed but still enjoy this time at baby group with Raya’.
Alyssa noticed increased hypervigilance regarding weaning Raya onto solid foods, by carefully monitoring Raya’s food intake and worrying that she might starve. The therapist supported Alyssa in understanding the NHS recommendations around weaning at 6 months alongside milk intake (National Health Service, n.d.), and that the amount each baby eats varies depending on a range of factors. They developed criteria to assess Raya’s health and happiness beyond food intake, such as her smiling and having energy to play. Alyssa also noticed increased reassurance-seeking around Raya’s health, e.g. taking her temperature regularly, and worked with the clinician to reduce these behaviours.
Reclaiming and rebuilding
This area was considered with Alyssa from the beginning of therapy. Alyssa was encouraged to reflect on her values regarding motherhood now. She worked with the clinician to identify activities she engaged in with Raya that aligned with those values and demonstrated her ‘good enough’ mothering. For example, Alyssa reported that she enjoyed taking Raya to the park because the swings made Raya laugh, which in turn made Alyssa feel joyful. Through challenging avoidance, Alyssa began to enjoy attending baby groups and made social connections with other mothers. Alyssa also re-engaged with activities she previously enjoyed, such as going swimming once a week and asking her mother to babysit during this time.
To address feelings of betrayal and disappointment towards health services and move forward in her journey, Alyssa was supported to make a complaint to maternity services and to make recommendations based on her own experiences of what could help future mothers with breastfeeding support. Alyssa viewed this as ‘trying to right a wrong for others’ and ‘putting responsibility back onto the health system’.
Ending therapy
Towards the end of therapy, Alyssa and the clinician developed a therapy blueprint, agreeing on how Alyssa would continue their work together and strive to be her own therapist. The clinician wrote Alyssa an ‘end of therapy letter’, which further cemented Alyssa’s new, more compassionate view toward herself. Outcome measures and ratings around Alyssa’s hopes and goals for therapy, completed at the beginning and middle of therapy, were repeated. Following therapy, her depression and anxiety symptoms reduced to the mild range, trauma symptoms reduced on the PCL-5, and she reported feeling more bonded to Raya and more confident and self-efficacious as a mother.
Additional clinical considerations
Clinical supervision provides an important space for clinicians to reflect and develop in their practice (Bernard and Goodyear, Reference Bernard and Goodyear2019). Alyssa’s clinician utilised supervision to discuss and revise their formulation and treatment plan, and for signposting to resources on perinatal mental health, breastfeeding, and breastfeeding trauma. In addition, the clinician utilised supervision as a supportive space to reflect on their cognitive and emotional reactions towards the client. For example, the clinician reflected on not being a parent themselves, and their surprise at learning that breastfeeding was a contentious and emotive issue for some clients. They recognised their own potential biases and the need to avoid colluding with others who minimised the client’s distress, such as Alyssa’s mother and sister.
Whilst the formulation developed between Alyssa and the clinician was predominantly problem-focused, consideration was given to strengths and resources that supported Alyssa despite the challenges. These included her love for Raya, her determination to overcome her struggles, and some beliefs about being a positive mum to Raya. Alyssa also considered the culture and context which led to the difficulties she faced, including her challenging fertility journey and living in a society with stretched health service resources.
Discussion
A subset of mothers who have difficulties with initiating or maintaining breastfeeding experience this as traumatic, and reactions can include symptoms of PTSD, moral injury and depression. To date, no conceptualisation has been developed to address or guide treatment for breastfeeding trauma and moral injury reactions. This paper has drawn from the cognitive model for moral injury in PTSD (Murray and Ehlers, Reference Murray and Ehlers2021) to present an adapted version for the formulation of breastfeeding trauma. In particular, the model guides clinicians to focus on the impact of pre-existing and maintaining appraisals and contextual factors relevant to the breastfeeding mother. Applications for treatment, using TF-CBT, are also discussed.
Based on our clinical experiences, our proposed conceptualisation aims to be useful for a subset of mothers who present with subthreshold symptoms of PTSD through to meeting full diagnostic criteria, associated with their breastfeeding challenges and moral injury. For those who do not meet the diagnostic criteria for PTSD, but who experience part or all of their breastfeeding journey as subjectively traumatic and whose moral values have been violated, then caution and clinical judgement will need to be utilised, but elements of our conceptualisation may still be helpful. This is similar to recent literature, for example, around racial trauma (Lawton et al., Reference Lawton, Thwaites and Warnock-Parkes2025).
Whilst our conceptualisation may not reflect all experiences of breastfeeding mothers, it aims to provide a starting point where there is empirical and clinical guidance lacking. Clearly, differential diagnosis and collaborative individualised formulation are essential for the conceptualisation and treatment of postnatal difficulties. For example, if an individual presents with postnatal depression, including moral injury and intrusive images of breastfeeding, but these images do not encompass a current sense of threat, a Beckian longitudinal depression formulation (Beck et al., Reference Beck, Rush, Shaw and Emery1979) incorporating these aspects might be more clinically appropriate.
Research into women’s health issues has been historically limited (Department of Health & Social Care, 2022; The Academy of Medical Sciences, 2021), and perinatal mental health trauma has predominantly focused on birth experiences (Mind, 2024). Additionally, women experiencing these challenges may have been supported within community infant feeding teams and not necessarily had their difficulties recognised in such a way to support referrals to psychological therapy services. This paper aims to raise awareness of the impact of negative breastfeeding experiences on both mother and baby, and to develop the literature base for this under-researched and under-recognised area.
As with other CBT formulation models, an individualised view of a client’s difficulties and the processes that maintain them is presented, with less consideration given to the broader system around the mother. For example, resources can be limited to support breastfeeding, given the wider financial and staffing challenges faced by health services (Jefferies and Wickens, Reference Jefferies and Wickens2025). This, in turn, can impact the sense of betrayal and anger the mother may feel when breastfeeding is both promoted as the gold standard of feeding and yet not followed up by adequate postnatal support. Therefore, breastfeeding trauma could also be addressed on a systemic level by supporting mothers with greater resources and, in doing so, shifting responsibility from the individual to the system.
Limitations and areas for further research
The proposed conceptualisation is theoretical. The clinical applicability and degree of helpfulness in making sense of traumatic breastfeeding experiences and moral injury, and thus for guiding therapy, need testing out. When an individual has experienced their breastfeeding journey as both traumatic and transgressing their expectations, the model may be clinically useful, but caution will need to be exercised to ensure that PTSD is neither implied nor diagnosed unless a comprehensive PTSD assessment has taken place.
A priority for further research in this area is to assess the experiences and extent of breastfeeding trauma and moral injury in mothers, and the prevalence of post-traumatic stress symptomatology. Particular attention needs to be paid to Criteria A (Stressor) and B (Intrusions) of the diagnostic criteria for PTSD if using the DSM-5 (American Psychiatric Association, 2013) to ensure that the subjective experience of trauma is not conflated with diagnostic criteria. Furthermore, we hypothesise that the neurological changes that occur during the perinatal period may impact the cognitive processing of the breastfeeding experience. However, more research is needed in this area.
This paper utilises the terms ‘mother’ and ‘breastfeeding’. However, further research and consideration are needed to consider how breastfeeding trauma might impact those whose gender identity does not align with their biological sex at birth, for example, transgender women who wish to chest feed, or a different gestational relationship, such as non-birthing parents who wish to initiate lactation to breastfeed their children. Particular considerations may be needed regarding prior beliefs and experiences, as well as additional contextual factors during the perinatal period. Further work is needed to consider appropriate adaptations for these diverse groups who may be impacted by breastfeeding trauma. Additionally, cultural expectations and norms vary significantly, so the conceptualisation’s applicability and appropriate adaptations need to be considered cross-culturally.
Piloting our proposed conceptualisation within perinatal mental health services, collecting quantitative data on clinical outcomes, and gathering qualitative feedback from clients and clinicians are the authors’ suggested next steps in this area. For mothers who have experienced difficulty breastfeeding but for whom our proposed conceptualisation is not clinically appropriate, developing other conceptualisations and clinical guidance will be important.
The authors of this paper identify as mothers with first-hand experience of breastfeeding and are supportive of all parents’ rights to choose regarding infant feeding. The authors are therefore mindful of the lens through which they present this paper.
In conclusion, the current paper proposes a conceptualisation of moral injury arising from traumatic breastfeeding experiences to help inform services and clinicians working with perinatal mothers, enhance treatment for individuals experiencing moral injury related to breastfeeding, and guide further research.
Key practice points
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(1) Traumatic breastfeeding experiences can be viewed through the lens of moral injury i.e. when an individual’s moral code in relation to beliefs about feeding, parenthood and identity is transgressed, and this can lead to a range of clinical presentations, including but not limited to PTSD and depression.
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(2) Individualised assessment and formulation, which centres on understanding beliefs and appraisals related to traumatic feeding experiences and moral injury, are key to treating clinical presentations that arise from breastfeeding trauma.
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(3) The paper is relevant for individuals working in perinatal, infant and mental health fields, for antenatal and clinical educators, and for incorporation into clinical service guidance and training requirements, e.g. NHS Talking Therapies positive practice guidelines for perinatal mental health (O’Mahen et al., Reference O’Mahen, Healy, Haycock, Igwe, Chilvers and Butterworth2023) and the University College London (UCL) perinatal competency framework (University College London, 2021).
Data availability statement
No new data was created or analysed for this paper, therefore data sharing is not applicable to this article.
Acknowledgements
We would like to thank Jo Billings for her feedback and guidance on key concepts and publication, Harriet Holroyd for her feedback based on clinical experience with breastfeeding trauma, and Ramesh Perera-Delcourt for providing advice from his research experience. We would also like to thank Hannah Murray, whose clinical and academic work has inspired the authors for many years, and for the incredible legacy she gave the field of trauma and PTSD.
Author contributions
Manveer Kaur: Conceptualization-Lead, Project administration-Lead, Resources-Equal, Visualization-Equal, Writing - original draft-Lead, Writing - review & editing-Equal; Rosie Powling: Conceptualization-Supporting, Project administration-Supporting, Resources-Supporting, Visualization-Supporting, Writing - original draft-Supporting, Writing - review & editing-Lead; Bethany Chapman: Conceptualization-Equal, Resources-Supporting, Visualization-Supporting, Writing - original draft-Supporting, Writing - review & editing-Supporting.
Financial support
This work received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethical standards
The authors confirm that they have abided by the Ethical Principles and Code of Conduct as set out by the BABCP and BPS. ‘Alyssa’ is a fictional case study, grounded in clinical experience.
Generative AI usage statement
The software Grammarly (v1.2.208.1781) was used on 31 October 2025 and 19 May 2026 to support the editing process, in identifying grammatical and spelling errors and to improve overall clarity of the text. The authors are entirely responsible for the scientific content of the paper, and the paper adheres to the journal’s authorship policy.
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