For decades, the narrative surrounding motherhood has been tightly bound to a culturally manufactured archetype: endless joy, seamless adaptation, and an all-encompassing, unquestioning fulfillment. Yet, behind closed nursery doors, a far more complex and often harrowing reality unfolds for millions of new parents.
The conversation surrounding maternal mental health reached a profound cultural crossroads with the high-profile legal proceedings of Lindsay Clancy—a Massachusetts mother and nurse who killed her three young children in 2023 before attempting suicide. During the investigation, authorities discovered a copy of Karen Kleiman’s seminal book, Good Moms Have Scary Thoughts, in Clancy’s kitchen cabinet. This revelation cast a blinding spotlight on a text designed to destigmatize the terrifying, unwanted intrusive thoughts experienced by more than 90% of new parents, thrusting perinatal mental health into the center of national debate, legal scrutiny, and public misunderstanding.
To truly understand what it means to sit with mothers in distress, one must look to pioneers who built the field from the ground up. Karen Kleiman, MSW, founder of The Postpartum Stress Center and an internationally recognized authority in perinatal mental health, has spent decades advocating for the mental well-being of postpartum women. Long before maternal mental health entered the mainstream medical lexicon, Kleiman was forging a path through a healthcare system that routinely dismissed maternal suffering as “normal” emotional upheaval.
In this comprehensive interview, Kleiman unpacks the profound implications of her work entering the public consciousness via the Clancy trial, explains the crucial medical distinctions between anxiety-driven intrusive thoughts and psychiatric emergencies like postpartum psychosis, and issues an urgent call to action for the healthcare community: We cannot wait for very sick women to tell us how much they are suffering.
Detailed Chronology: The Evolution of Perinatal Advocacy and Cultural Reckoning
The 1980s: Paving a Path in Uncharted Territory
When Karen Kleiman began working with postpartum mothers experiencing perinatal mental health conditions in the 1980s, the modern landscape of maternal mental healthcare essentially did not exist in the United States. Mothers struggling with depression, anxiety, and frightening internal states were overwhelmingly met with silence, isolation, and institutional dismissal.
"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," Kleiman recalls. "I became curious about this reluctance to disclose the extent to which they were suffering."
Drawn to suffering through the lived example of her mother—a German Holocaust survivor who modeled how to "suffer well" while maintaining a fierce dedication to life—Kleiman recognized early on that individuals could be simultaneously symptomatic and competent. This foundational realization fueled her mission to advocate for postpartum women who lacked the words or physical stamina to articulate their needs.
Encountering Institutional Resistance
As Kleiman attempted to sound the alarm on maternal distress, she met formidable resistance from the established medical community. OB/GYNs and primary care physicians were historically trained to view emotional volatility as a standard, benign byproduct of adjusting to a newborn.
When Kleiman queried medical colleagues regarding this collective dismissal, the response exposed a systemic blind spot. Healthcare providers simply lacked the tools, time, and training to differentiate between normal postpartum adjustment and clinical pathology. Refusing to be deterred, Kleiman weaponized her exasperation into a catalyst for advocacy. She began creating accessible screening tools, patient information sheets, and office posters designed to bridge the chasm between struggling mothers and overworked medical staff.
The Publication of Good Moms Have Scary Thoughts
Recognizing that clinical language often alienates and terrifies vulnerable parents, Kleiman authored Good Moms Have Scary Thoughts. The book was deliberately engineered to rebrand "intrusive thoughts"—unwanted, disturbing mental flashes of harm coming to the infant—into "scary thoughts," making a frightening psychological phenomenon approachable, universal, and non-pathological. By pairing heavy, destigmatizing subject matter with lighthearted, validating illustrations, Kleiman provided women across the globe with a linguistic lifeline.
The Lindsay Clancy Trial and the National Spotlight
The cultural footprint of Kleiman’s work expanded dramatically when Good Moms Have Scary Thoughts emerged as an exhibit during the trial of Lindsay Clancy. The revelation that a copy of the book resided in Clancy’s kitchen cabinet ignited intense public speculation about the intersection of postpartum mental illness, legal accountability, and literature designed to help struggling mothers.
While the presence of a self-help book cannot quantify an individual’s complex clinical state, the trial forced mainstream society to confront an uncomfortable truth: help-seeking behaviors can appear entirely ordinary on the surface while severe, life-threatening psychiatric distress simmers below.
Supporting Context & Metrics: The Hidden Landscape of Maternal Distress
To contextualize Kleiman’s insights, one must examine the broader statistical and clinical realities governing maternal mental health:
The Prevalence of Intrusive Thoughts: Clinical studies consistently show that over 90% of new parents experience unwanted, intrusive thoughts of harm involving their infants. These thoughts are ego-dystonic—meaning they are deeply horrifying and fundamentally opposed to the parent’s actual desires or intentions.
The Spectrum of Postpartum Mood Disorders: While postpartum depression and anxiety affect roughly 1 in 7 new mothers, severe psychiatric conditions like postpartum psychosis are acute medical emergencies, occurring in approximately 1 to 2 per 1,000 births.
The Healthcare Gap: Despite universal screening recommendations by organizations like the American College of Obstetricians and Gynecologists (ACOG), a staggering number of maternal mental health cases go undiagnosed due to systemic time constraints, provider discomfort, and the inherent masking behaviors perfected by suffering mothers.
The Interview: Karen Kleiman on the Front Lines of Maternal Mental Health
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 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.
Future Outlook: Transforming Maternal Healthcare
As the medical, legal, and cultural landscapes continue to evolve in the wake of high-profile cases like that of Lindsay Clancy, the imperative for systemic reform in maternal mental healthcare has never been more apparent. Moving forward, experts emphasize several critical areas for development:
Mandatory Clinician Training: Expanding perinatal mental health education beyond specialized psychiatric settings into standard OB/GYN, pediatric, and general practice residencies.
De-stigmatization at Scale: Normalizing maternal ambivalence and intrusive thoughts in prenatal classes so parents are equipped with psychological safety nets before distress occurs.
Proactive Intervention Protocols: Shifting away from passive screening questionnaires toward active, relational clinical engagement that looks beyond a patient’s outward veneer of competence.
Accessible Higher Levels of Care: Ensuring that specialized mother-baby inpatient psychiatric units are widely available and adequately funded, eliminating the dangerous treatment gaps that currently leave severe cases vulnerable to tragic outcomes.
Ultimately, Karen Kleiman’s enduring message serves as both a warning and a mandate: until healthcare systems learn to listen to what mothers are not saying, and until society completely dismantles the punitive perfection myth of motherhood, families will continue to navigate the darkest corridors of perinatal distress entirely alone.
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, expanded, and edited for high-level journalistic publication.
