By Cassie Shortsleeve
Updated Sep. 02, 2026
In the complex landscape of perinatal mental health, few names carry as much weight or historical significance as Karen Kleiman, MSW. As the founder of The Postpartum Stress Center and a leading international expert in maternal mental health, Kleiman has spent decades pioneering a field that largely did not exist in the United States when she began her work in the 1980s. Today, her foundational book, Good Moms Have Scary Thoughts, has entered the public consciousness in an unexpected and high-profile way: it was found in the kitchen cabinet of Lindsay Clancy, the Massachusetts mother and nurse who killed her three young children in 2023 before attempting suicide.
The inclusion of Kleiman’s book in the ongoing legal discourse surrounding the Clancy trial has thrust the harrowing realities of severe postpartum psychiatric illness into the national spotlight. For years, Kleiman has advocated for mothers experiencing intrusive thoughts—unwanted, distressing mental images or impulses that more than 90 percent of new parents experience—working tirelessly to destigmatize conditions that many mothers feel too ashamed or terrified to articulate.
Reflecting on her decades of service, Kleiman notes that she has always been oddly drawn to suffering. Her personal perspective was deeply shaped by her mother, who immigrated to the United States from Germany following the Holocaust. Her mother modeled how to endure profound suffering while maintaining an unwavering determination to live and move forward, teaching Kleiman that it is entirely possible to be both symptomatic and competent at the same time—a foundational concept she frequently shares with her clients and students.
When Kleiman first began meeting with mothers experiencing perinatal mental health challenges in the 1980s, she quickly noticed a troubling pattern: many women were struggling profoundly, yet almost none of them felt comfortable or safe talking about it. This reluctance to disclose the true extent of their distress sparked a lifelong curiosity and a fierce dedication to advocacy. She found herself invigorated by the possibility of speaking up for postpartum women who lacked the words or physical stamina to express their own needs.
Yet, this advocacy was met with significant resistance from the broader medical community. Kleiman recalls that many healthcare providers, including OB/GYNs, were trained to expect a certain degree of emotional upheaval during the postpartum period, often dismissing any expression of emotional distress as a normal and expected response to motherhood. This collective dismissal was both exasperating and deeply motivating for Kleiman. Rather than backing down, she used her frustration to fuel creative ways to penetrate the healthcare barrier and make medical professionals’ jobs easier. She developed screening tools, patient information sheets, and office posters designed to educate both patients and clinical staff about the reality of postpartum depression and anxiety. Over time, these efforts were largely met with appreciation and a growing clinical awareness that maternal distress demanded serious attention.
The centerpiece of much of Kleiman’s educational outreach is her widely read book, Good Moms Have Scary Thoughts. The anxiety associated with perinatal mood disorders—particularly when it involves depression or unwanted, intrusive thoughts of harm coming to an infant—can be entirely debilitating and exceedingly difficult to voice. Kleiman points out that this silence often increases anxiety and reinforces negative thought patterns, trapping mothers in a dangerous spiral of despair. By explicitly labeling "intrusive thoughts" as "scary thoughts," the book deliberately shifts away from heavy clinical or pathological terminology, making the concepts far more approachable and less frightening for vulnerable parents.
The unique impact of the book stems from its careful intersection of heavy, difficult subject matter with lighthearted, empathetic illustrations. This design choice serves to validate mothers’ experiences immediately, cutting through the thick layers of isolation and shame that so frequently accompany early parenthood. Furthermore, the book empowers mothers to advocate for their own needs by providing journal prompts and tangible resources, offering a crucial lifeline to women who might otherwise lack access to adequate professional support.
When confronted with the fact that her book has become a point of discussion during the high-profile Lindsay Clancy trial, Kleiman approaches the subject with characteristic nuance. She emphasizes that the presence of a mental health resource in a home tells observers very little about a person’s precise clinical state at any given moment, but it powerfully underscores why accessible, destigmatizing resources are so urgently needed. Help-seeking can appear entirely ordinary from the outside, while the internal suffering hidden beneath the surface remains extraordinarily complex. A mother frightened by her own thoughts often worries that speaking her truth out loud will brand her as a bad parent or cause others to question her fitness. Providing the right information in an accessible format serves as a vital first step toward breaking that silence.
The current legal proceedings have also forced postpartum psychosis into broader public conversations, raising difficult and essential questions about how society and healthcare systems respond to maternal distress. Kleiman stresses that women can actively seek help and still fall through the cracks of a fragmented healthcare system. Postpartum women are remarkably skilled at presenting themselves as "fine" to the outside world for a multitude of reasons. However, when mothers become severely ill, their difficulty or hesitation in disclosing their true internal state can carry tragic consequences.
According to Kleiman, the medical community and support networks cannot afford to wait for extremely sick women to come forward and quantify their suffering. Maternal care providers must actively look patients in the eyes and ask the difficult questions. Clinicians need to explore what a mother is trying to communicate, evaluate her needs, gather observations from those closest to her, monitor treatment response, and coordinate with other providers to ensure a unified clinical picture. Crucially, when a mother begins to deteriorate, providers must recognize swiftly when her needs exceed outpatient treatment capabilities and intervene accordingly.
This level of vigilant clinical assessment is especially critical when evaluating the possibility of postpartum psychosis. Distinct from postpartum depression, anxiety, or obsessive-compulsive disorder, postpartum psychosis is a true psychiatric emergency that occurs in approximately one to two out of every one thousand births. It can manifest through delusions, hallucinations, severe mood shifts, confusion, disorganized thinking, and fluctuating insight, requiring careful and expert evaluation.
Intrusive thoughts can complicate this clinical picture further, as unwanted thoughts regarding harm to an infant are common during the postpartum period and can occur in individuals both with and without underlying psychiatric conditions. When these thoughts appear as isolated intrusive phenomena driven by anxiety, a mother typically experiences them with a questioning mindset, asking herself "what if?" Conversely, when intrusive thoughts are embedded within an active psychotic process, the experience is often perceived by the mother as an absolute reality. Evaluating the broader clinical picture—including insight, reality testing, overall mood, behavior, sleep quality, daily functioning, and treatment response—is essential for distinguishing between an anxiety-based thought process and a psychiatric emergency.
Beyond clinical diagnoses, Kleiman’s work consistently highlights a universal truth of the human experience: mothers rarely feel just one single emotion about their new reality. Instead, they experience a complex matrix of contradictory feelings, proving that two opposing things can be true at the exact same time. Kleiman explains that women’s struggles with conflicting emotions are heavily driven and reinforced by rigid cultural ideologies and societal expectations, which in turn set the stage for enduring guilt and anguish.
Embracing this emotional dichotomy allows mothers to process unexpected grief and loss, liberating them from fear and guilt while guiding them toward self-acceptance and well-being. By normalizing maternal ambivalence as a healthy and expected component of maternal love—and making it safe for women to express contradictory emotions—society can pave the way for genuine acceptance and empowerment.
When considering what must change in the broader response to maternal suffering, Kleiman points directly to the training and mindset of perinatal clinicians. While screening protocols and formal diagnoses are necessary components of care, they represent only a fraction of the required work. Clinicians must cultivate a deep understanding of the subtle nuances of maternal distress, recognizing that severe suffering can easily coexist with external competence and high functioning. This requires ongoing professional education, deep clinical presence, and an environment where a mother feels truly safe to reveal her authentic thoughts and experiences.
Ultimately, Kleiman argues that the professional responsibility of maternal healthcare providers extends far beyond simply identifying symptoms. It demands a genuine commitment to understanding the individual experiencing them, maintaining persistent curiosity about the nature of her suffering, listening carefully to what is spoken, and paying close attention to what remains unsaid before a crisis takes root.
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.
