‘We cannot wait for very sick women to tell us how much they are suffering’
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Karen Kleiman, MSW on her popular book, ‘Good Moms Have Scary Thoughts,’ the Lindsay Clancy Trial, and taking moms’ mental health seriously.
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Recently, a popular book, Good Moms Have Scary Thoughts—which you may have heard of or read yourself—has emerged in the trial of Lindsay Clancy, the mother and nurse who killed her three young children in 2023 before attempting suicide. Police found a copy of it in Clancy’s kitchen cabinet. The book, by Karen Kleiman, MSW, works to destigmatize intrusive thoughts, which some 90%+ of new parents experience.
I first connected with Kleiman, who is the founder of The Postpartum Stress Center and a leading international perinatal mental health expert, years ago when I started reporting on maternal mental health. Sources told me that to really understand what it was like to sit with moms in distress, to really understand moms’ stories, I should talk to her. Kleiman is an educator and a skilled provider who trailblazed a path in a field that largely didn’t exist in this country before she came around. She’s also the type of person you’d want to meet with if you were struggling. She brings humanity, compassion, nuance, and deep understanding to a field that so desperately needs it (one of her books is called The Art of Holding in Therapy).
Kleiman spoke to me about her book being part of the discussion around the Clancy trial—as well as why she’s drawn to suffering, what to know about intrusive thoughts, and how we must start listening to moms long before they’re crying for help.
Q: You’ve said that when you started in this field you were interested in exploring the ‘darker side of motherhood’—that it was both motivating and exasperating. Tell us about that.
Karen Kleiman: I have always been oddly drawn to suffering. My mother came to the United States from Germany during the Holocaust and role-modeled for me how to suffer well. She was determined to balance her suffering with her strong desire to live and move forward. I learned that it was possible to be symptomatic and competent at the same time. It’s a concept I often reiterate to clients and students.
When I started working with moms with perinatal mental health conditions in the 1980s, I noticed that many moms were not feeling good—and most of them were not okay talking about that. I became curious about this reluctance to disclose the extent to which they were suffering.
I also remember feeling invigorated by the possibilities that could develop when advocating for postpartum women who could not find the words or stamina to express what they needed. All the while, I continued to meet with postpartum moms in distress who expressed over and over that it was just easier to shut down and retreat in silence. The resistance from the medical community seemed to rouse my competitive nature. I embraced it. It made me work harder to get the word out that postpartum moms were not telling medical professionals how they felt and what they needed. But I began wondering: Why the collective dismissal?
A friend of mine who was an OB/GYN explained that she was trained to expect a certain degree of emotional upheaval; any expression of emotional distress would be lumped together as a “normal” response to motherhood. The exasperation I felt at that was motivating. My frustration with the closed minds and set-in-their-ways responses drove me to find creative ways to penetrate this healthcare barrier.
I set out to make the OB/GYNs’ jobs easier. I created screening tools, patient information sheets, posters for their offices, and anything to help patients and staff learn that there was important information they might be missing and that there was help for postpartum depression and anxiety. For the most part, these efforts were met with appreciation and, for some, a new awareness that there was something very real happening that deserved more attention.
Q: I want to start a petition to get every new mom a copy of your book Good Moms Have Scary Thoughts. Tell us about the book.
KK: The anxiety associated with topics such as depression or negative unwanted thoughts of harm coming to your baby can be debilitating—and extremely hard to talk about. This disinclination to reveal feelings, however, can increase anxiety and reinforce negative thoughts, leaving moms in a spiral of despair. In Good Moms Have Scary Thoughts, we labeled “intrusive thoughts” as “scary thoughts” and tried to make them sound and feel less clinical, less pathological, and more approachable.
The magic of the book comes from the intersection of the difficult subject matter and the lighthearted nature of the illustrations. The book is enormously validating, reducing both stigma and isolation.
My personal pride in it comes from its ability to help moms advocate for themselves by drawing them into the difficult subject matter and reducing shame. It then provides journal prompts and resources for further support, which empower moms to follow up with how they are feeling, especially those who may not have access to the support and resources they need.
Q: Good Moms Have Scary Thoughts has received attention during the Lindsay Clancy trial. What does it mean to you to see the book discussed in that context?
KK: I wrote Good Moms Have Scary Thoughts to give women language for experiences they are often terrified to disclose. We intentionally made the book visual, accessible, and approachable because asking for help can be difficult when a mother is ashamed or frightened by what she is experiencing.
The presence of a mental health resource tells us very little about a person’s clinical state, but it does remind us why accessible resources matter. Help-seeking can look very ordinary from the outside while the suffering underneath may be far more complicated.
A mother who is frightened by her thoughts may not know whether what she is experiencing is common, clinically significant, or something she should tell someone about. She may fear that saying the words out loud will make someone think she is a bad mother.
Sometimes the right information, presented in an accessible way, can be a first step toward breaking that silence and giving a mother permission to reach out.
Q: The current trial has also put postpartum psychosis into the public conversation, raising important and difficult questions. What do you wish people understood about postpartum psychosis and intrusive thoughts?
KK: We have become acutely aware that women can actively seek help and still not receive the recognition or care they need. For decades, I have wondered why so many postpartum women in distress continue to fall through the cracks of our healthcare system. Postpartum women are extraordinarily good at presenting themselves as “fine” for many reasons. But when women are severely ill, their difficulty or reluctance to disclose what they are experiencing can have serious consequences.
We cannot wait for very sick women to tell us how much they are suffering.
Maternal care providers need to make sure they are looking into her eyes and asking the hard questions. What is she trying to communicate? What does she need us to know? What do the people closest to her tell us? How is she responding to treatment? What are her other providers observing, and are we all seeing the same clinical picture? And when a mother is deteriorating, how quickly can we recognize that she may need a level of care beyond what outpatient treatment can provide and intervene accordingly?
Recognizing when a mother needs a higher level of care is especially important when postpartum psychosis is a possibility. Postpartum psychosis is not postpartum depression, anxiety, or OCD. It is a psychiatric emergency, occurring in approximately 1 to 2 per 1,000 births. It can involve delusions, hallucinations, severe mood symptoms, confusion, disorganization, and fluctuating insight. Its presentation can vary considerably, making careful assessment essential.
Intrusive thoughts can further complicate that assessment. Unwanted thoughts of harm coming to the baby are common in the postpartum period and can occur in women with and without psychiatric disorders. When they occur as isolated intrusive thoughts, they are not, in themselves, associated with an increased risk of infant harm.
What matters clinically is how the mother experiences and understands the thought. When intrusive thoughts are anxiety-driven, a mother may ask, “What if…?” When they are embedded in a psychotic process, the experience may be, “This is true.” The broader clinical picture, including insight, reality testing, mood and behavior, sleep, functioning, and response to treatment, helps determine whether the thought is part of an anxiety-based intrusive-thought process or a psychotic process.
Q: Good Moms Have Scary Thoughts also highlights a universal truth: that often, we don’t feel just one way about something, but rather, we feel many different ways. That two things can be true. Why do you think it’s so common to struggle with that idea?
KK: Women’s struggle with conflicting emotions around motherhood is largely driven and reinforced by cultural ideologies and societal expectations. This sets the stage for significant and enduring guilt, anguish, and a multitude of other powerful and negative emotions.
Q: And what’s the benefit of letting all of these emotions live together?
KK: Our understanding of this dichotomy can help us understand unexpected feelings of grief and loss, liberating us from fear and guilt and guiding us toward self-acceptance and well-being. This is how we transform throughout the journey of motherhood. I would argue that when we normalize maternal ambivalence as a healthy component of motherly love and make it safe for women to express and integrate the presence of contradictory emotions, we pave the way for acceptance and empowerment.
Q: If you could change one thing about the way we respond to maternal suffering, what would it be?
KK: I would love to see perinatal therapists become much more skilled at recognizing and responding to the nuances of maternal suffering. Screening and diagnosis matter, but they are only part of the work.
Perinatal clinicians need to understand the complexities of maternal distress and recognize suffering that can exist alongside competence and functioning. That kind of clinical understanding requires ongoing learning and a willingness to continually examine and strengthen how we show up with the women we treat. Clinical presence is part of the intervention itself, creating the conditions in which a mother may feel safe enough to reveal what she is truly feeling, thinking, and experiencing.
Our professional responsibility extends beyond identifying symptoms. It requires us to understand the person experiencing them, remain curious about the nature of her suffering and what we may be missing, listen to what is being said, listen for what is not being said, and determine when routine support is no longer enough.
We need to get better at recognizing suffering before it becomes a crisis.
This interview originally appeared on Two Truths, a bestselling newsletter by health journalist Cassie Shortsleeve and Motherspeak creator Kelsey Haywood Lucas. It has been adapted and edited.
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