Postpartum psychiatry built a reassuring message and delivered it well. Unwanted thoughts of harm coming to a baby are near-universal in the weeks after birth, they do not predict violence, and the fact that a mother finds them repellent is itself the evidence that she is not psychotic. Ellen Barry’s reporting in The New York Times describes what happens when one case gives that message a hard counterexample, and when the specialists who taught it start revising in public.
The clinical facts, first, because they are the part that deserves to be more widely known. Intrusive thoughts are unbidden images, words or urges, classically associated with anxiety disorders and O.C.D. A 2022 study by Nichole Fairbrother following 763 Canadian women for six months found 96 percent reported thoughts of accidentally harming their infant — mostly suffocation or crib death — and 54 percent reported thoughts of intentionally harming the baby, by shaking it or screaming at it. Intensity peaked in the first two months and largely resolved within six months. A 2008 paper by Fairbrother and Sheila Woody found that parents reporting intentional-harm thoughts were unusually vigilant: they checked on the baby more and avoided situations they read as dangerous. Researchers have found no association between these thoughts and abuse, and there is a plausible mechanism — reproductive hormones routed toward the machinery that produces vivid imagery, preparing a parent for vigilance rather than harm.
Karen Kleiman has been the most effective popularizer of that reassurance. Her 2019 book Good Moms Have Scary Thoughts was distributed by hospitals, and when it worked, it worked because it let women say the unsayable. “It is my experience that her anxiety will go from a 10 to a five,” she told Barry, “because someone who knows what they’re talking about is telling me I’m OK.”
The test she no longer trusts
Her screening rule was simple and widely used: if a mother found the thought horrifying, she wasn’t psychotic. In psychosis, by contrast, a person finds the thought believable and justified. “I had a lot of certainty before this case,” Kleiman now says. “Well, we can’t do that anymore, from this day forward.” She recommends clinicians who hear frightening thoughts also look for mania, confusion and paranoia, and has approached her publishers about changing the book’s text and illustrations. “What we’re really learning is how much we don’t know. How much the experts don’t know.”
The case is that of Lindsay Clancy, tried for killing her three children, whose jury could not reach a verdict. Barry — who covers psychiatry for the Times and attended the trial while reporting a book on postpartum mental health — treats the trial as evidence rather than spectacle. Clancy kept a diary of her symptoms while cycling through regimens in late 2022: “Intrusive thoughts” on Dec. 8, “horrible intrusive thoughts” the next day, “HORRIBLE thoughts” with both words underlined by the 14th. Her illness followed an atypical path: from September 2022 she reported anxiety attacks, depressed mood, racing thoughts and an inability to sleep or feel pleasure; clinicians diagnosed general anxiety disorder, bipolar disorder and major depressive disorder at different points and started 13 psychotropic medications between them, several of which she said caused insomnia and emotional numbing. In late November she first mentioned intrusive thoughts to her psychiatrist — at that stage they were mainly suicidal. In mid-December she told her mother and husband she had thoughts of harming the children. She has said that on Jan. 23, 2023, she heard a male voice telling her to kill her children: a command hallucination, which her defense argued was postpartum psychosis.
That diagnosis is rarer than the reassurance literature implies — it affects 1 to 2 of every 1,000 new mothers — and it is a psychiatric emergency that usually dictates hospitalization. It is also treatable.
Where the specialists split
Barry’s most useful service is not adjudicating the case but showing that clinicians disagree about the boundary itself. Jonathan Abramowitz of U.N.C. Chapel Hill calls the two experiences “qualitatively different”: O.C.D. thoughts produce a fear response, psychotic thoughts get a person to “wrap their reality around” them. He has never treated a patient whose frightening O.C.D. thoughts became delusions; if it happened, he would reassess the diagnosis. Fairbrother says the same, more strongly — anxious thoughts becoming psychotic “is not on the table as an option. It would be because a new, separate, parallel disease was happening.”
Others have seen the transition. Dr. Uruj Kamal Haider describes a patient who understood her intrusive thoughts weren’t real until three sleepless nights preceded a commanding voice ordering her to poison the family dog; “what was clear is that she developed this sudden loss of insight.” Dr. Julia Riddle has seen a handful of similar cases on a perinatal inpatient unit, where a mother’s fear of taking the baby outside hardens into the concrete conviction that the world is unsafe. “You do sort of tip into psychotic thoughts. It becomes a delusion.” Her practical answer is collateral information: talk to the people around the patient, who notice emerging paranoia before the patient reports it.
Why the revision matters
The stakes here are disclosure, not diagnosis as an end in itself. Fairbrother’s point is that generations of women have withheld severe intrusive thoughts out of fear that their children would be taken away — and she calls the fear reasonable: “The chances they are met with a child-abuse related response is still very high.” A screening rule that offers blanket reassurance is only as good as the clinician applying it; a rule that has been shown to have exceptions, handled well, may do less harm than a message that makes a mother feel she is the one case that proves she is dangerous. Riddle’s framing is the one to hold: women with postpartum disorders are “not villains or bad mothers,” and the point of the conversation is that they feel able to get treated.
Two caveats belong at the end. A hung jury decided nothing, and Clancy’s clinical history comes largely from adversarial testimony. And the disagreement Barry documents is a disagreement — the clinicians who have never seen loss of insight say so from experience, which is not the same as evidence that it cannot happen. What the case has done is convert a confident reassurance into a question, at a moment when the answer has to be given to someone who is frightened and asking.