When Reporting Becomes the Harm: Postpartum

There may be no mental health symptom more vulnerable to misunderstanding than a mother saying, “I had a thought about hurting my child.”

Those words can describe radically different psychological events. They can describe desire and intent derived from psychosis or the exact opposite: an inauthentic, illegitimate, ego-dystonic thought that begins an inner Anxiety or OCD cycle, where no proof is ever enough.

The English language collapses all of those experiences into the same phrases, such as

She “thought” about it.

It was an “intrusive” thought.

She “doesn’t want” to do it.

The difference between the two actual contexts is the ego-dystonicity, or in simpler terms, the inner authenticity.

Typically, I write about and teach ego-dystonic, or inauthentic, thoughts in the context of OCD. In this article, however, I’ll broaden that discussion: my anecdotal clinical experience has repeatedly shown that people with generalized anxiety and other anxiety presentations can also experience intrusive, taboo thoughts.

Postpartum Obsessive Compulsive Disorder is characterized by unwanted intrusive thoughts, images, or what feels like anxious urges of physical or sexual abuse towards the person’s children.

These are typically sudden “flash” mental images of dropping the child, drowning the child in the bathtub, molesting the child, stabbing the child, or somehow losing control and doing something horrific. The most important clinical information is not simply the content of the thought, but the person’s inner relationship to it. That distinction can determine keeping children safe, whether a clinician treats OCD, or whether a clinician accidentally reinforces OCD.

The surface-level interpretation can feel intuitive: a mother is imagining harming her baby, therefore she must be dangerous.

OCD and Anxiety often work to avoid danger that isn't present. A mother may avoid bathing her child because an image of drowning the baby appeared in her mind. She may stop cooking because seeing a knife triggers an image of stabbing the baby. She may refuse to carry the baby downstairs because she imagines dropping him. She may insist another adult remain in the room because she fears that being alone with the child could somehow cause her to “lose control" or go on "autopilot abuse".

These behaviors may outwardly appear as though the parent is detached, does not care about the child, or is being neglectful. In reality, the parent may be hiding both the inauthentic intrusive thoughts and the distress surrounding them, while engaging in repeated internal attempts to disprove their legitimacy despite an underlying recognition that the thoughts do not reflect their actual desires or intent, for even one mildly extended moment.

These behaviors are not merely side effects of the disorder; they can become compulsions themselves. Reassurance seeking, checking, avoidance, thought suppression, confession, and repeated attempts to achieve absolute certainty can all become part of the OCD or broader anxiety cycle.

The mother is not moving toward the feared act. She may be reorganizing her entire life trying to make it impossible.

Why Seeking Professional Help Can Be Dangerous

Parents who disclose postpartum intrusive thoughts can be reported to Child Protective Services, sent for emergency psychiatric evaluation, involuntarily hospitalized or sectioned, prohibited from being alone with their child, or separated from the child entirely. They may even request this, and have Post Partum Anxiety or Post Partum OCD the entire time.

Aside from ego-dystonicity, where the thought itself produces repulsion rather than a concealed or sustained attraction to its content, there are often other “tells” that point away from genuine danger. A person who is not acting from authentic intent may panic over the thoughts, confess them, repeatedly seek reassurance, and become trapped in endless “what if…” hypotheticals.

The cycle is driven by internal gaslighting over the ambiguous verbiage we use to describe mental experiences: I thought about it. I imagined it. It crossed my mind. I felt something. OCD and severe anxiety can seize on those imprecise phrases and repeatedly reinterpret them as evidence, even when the person’s emotional reaction, behavior, values, and underlying intent point in the opposite direction.

For a person already trapped in an OCD cycle centered on the possibility that they may secretly be dangerous, these interventions can become devastating confirmation of the obsession. The parent may think: If professionals heard this thought and decided my child needed protection from me, maybe I really could become one of those parents who kills their child. 

What began as an ego-dystonic thought can then expand into a much larger delusion-like OCD cycle of self-surveillance, avoidance, reassurance seeking, concealment, and repeated attempts to prove that they are not secretly capable of becoming the person they fear. In those cases, the intervention does not merely fail to treat the obsession; it can become part of the obsession itself.

Ego-dystonic intrusive thoughts are not exclusive to OCD. They occur in people with anxiety disorders and in people without psychiatric diagnoses at all. The person then notices that the forbidden thought entered consciousness and begins prosecuting themself for it.

“You technically “had thoughts about” it.”

That sentence can be enough to launch an entire OCD cycle of repeated self-gaslighting and repeated attempts to disprove the inner gaslight. The better approach outside of Exposure Therapy is to simply recognize the mental image or other ego-dystonic intrusive thought as a “brain fart”.

A person thinking, “I really want to hurt my baby, but I don’t, or I shouldn’t, let’s hide this and forget about it” is not describing the same mental event as a person thinking: Why did my brain just show me an image of hurting my baby? … Why did my brain just make my skin crawl and think it was an anxious urge to harm? … What if that means I secretly want to? … Why am I thinking about this? … Why am I picturing this? … What if I do? … What if I’m like that girl in the news? … She is just like me, I’m so scared I could. …How can I prove that I wont? .. and eventually “I went through this too.”

Unless you truly gathered items to kill or fought the extreme internal craving to kill or rape your child, you didn’t experience the same thing.

The phrase is identical. The psychological context is not.

This may be where postpartum OCD becomes most vulnerable to clinical misunderstanding. A psychiatrist or therapist may “intervene” on something that isn’t even legitimate. That can further separate the parent from their child and cause increased anxiety and depression as well as lifelong harm for the child.

Inverted Therapy

Exposure and Response Prevention or ERP is the gold standard for OCD or anxiety based ego-dystonic intrusive thoughts. As bizarre as this sounds, a new mom could enter the session, knowing what to expect, and begin pretending she does want to kill or rape her child. That could even take on role playing disgust, signing false confessions, false threats by the therapist of being institutionalized, sharing fake detailed plans on how these horrific events will be done, reading stories about parents who killed their children and pretending the patient is the same, or false positivity from the therapist about the patient having the thoughts.

ERP triggers an internal mechanism to not only spike anxiety and sit with it, but also to process the ego-dystonic thoughts on a subconscious and unconscious level so that the internal “click” repeatedly occurs and the patient has the inner certainty of these thoughts being dystonic. It also relieves the pressures of guilt, shame, fear of others knowing, and consequences for sharing them.

A good therapist will make the patient feel that they, the therapist, are actually sicker than the patient. I have used this tactic often and even asked for life advice towards the end of my patients care, after significant reduction in symptoms, to shift the dynamic and attempt to seal their unconscious mind with the feelings of confidence and assurance that they are mentally more well than the mental health provider from whom they once needed help.

Typically ERP takes 6 weeks before total and complete elimination of all symptoms and intrusive thoughts, if done correctly.

Workbooks for Exposure Therapy for Violent and other types of Taboo OCD / Anxiety are available on my website CoreHealingTherapy.org

For more about when inverted therapy becomes perverted therapy please see my article on Sexual Exposure Therapy with minors — https://medium.com/@daniel_carr/sexual-exposure-therapy-for-minors-c0fee7a3e984

If the woman is not accurately assessed and out of provider fear based counter-transference is given the approach of a truly dangerous person; protective authorities are contacted, the child is separated from her, she is hospitalized primarily because the thought exists rather than because of demonstrated intent, planning, impaired reality testing, loss of future orientation, or another clear marker of acute risk.

Instead of weakening thought-action fusion, the response can strengthen it. Instead of reducing avoidance, it formalizes avoidance. Instead of teaching that a thought does not require action, the system takes major action because the thought occurred. Instead of challenging the belief that “having the thought means something terrible about me,” the intervention may appear to validate it.

Postpartum Mental Illness Is Not Exclusively Maternal

There is another side of postpartum mental health that receives remarkably little public discussion: fathers can deteriorate after the birth of a child too.

The literature generally refers to this as paternal postpartum depression or, more broadly, paternal perinatal depression. Meta-analytic research has estimated paternal postpartum depression in roughly 8% to 9% of fathers during the perinatal and postpartum period, meaning the problem is neither hypothetical nor exceedingly rare.

Fathers and other non-childbearing parents so they are ignored. The fact fathers do get post-partum at at least 25% the rate of women, would challenge many modern ideas of fatherhood and the biological bond fathers have with their children. Fathers can also experience syntonic / authentic intrusive thoughts, severe anxiety, depression, and obsessive-compulsive symptoms during the transition to parenthood. Yet culturally, the word “postpartum” is still treated exclusively as a maternal concept.

That creates an obvious blind spot when fathers kill their partner and family. They are never said to have postpartum despite the signs clearly showing they are the same experience in different gendered bodies.

Lindsay Clancy and Why “Intrusive Thoughts” Cannot Be the Diagnosis

The distinction between postpartum OCD and more dangerous postpartum psychiatric states has become especially visible in the ongoing Massachusetts murder trial of

Lindsay Clancy, who killed her three children in January 2023 and then jumped from a second-story window, leaving her paralyzed.

Her defense argues that she was suffering from a severe postpartum psychiatric illness involving psychosis and that she was not criminally responsible for the killings.

Prosecutors argue that the deaths were intentional and planned. Testimony has also included references to Clancy reporting “intrusive thoughts” before the killings.

Whatever the jury ultimately concludes about her criminal responsibility, the case illustrates a crucial point: “intrusive thought” is a vague and ambiguous description.

The existence of cases like Clancy’s should not make every frightened mother who reports an intrusive image appear more dangerous. It should make clinicians more precise.

The question cannot simply be: “Did she think about harming the baby?”