Beyond the Symptoms: Are We Really Listening to Maternal Suffering?

“A good therapist will listen for the symptoms associated with the struggles of mothering. A trained therapist will listen to understand the suffering under the symptoms.” — Karen Kleiman

As the Lindsay Clancy case has unfolded in the courtroom and across social media, it has brought public attention to postpartum mental health and psychosis, raising difficult questions about how we recognize and respond to severe maternal mental illness.

And yet, in the quiet privacy of my therapy rooms, that public conversation feels much more personal. I am hearing fear and anxiety from mothers who are questioning their own thoughts and symptoms, alongside a growing uncertainty about whether they can trust the systems put in place to help them.

They want to know:

If I tell you what I'm really thinking or how badly I feel, will you protect me or dismiss me?

There are complicated legal and clinical questions surrounding this case that I cannot answer. But as a therapist specializing in perinatal mental health, the case has left me thinking about something much broader:

Are we truly listening to the depth of a mother's suffering, or are we identifying her symptoms without understanding the experience beneath them?

When We Listen Only for Symptoms

As trained mental health providers, we are taught to listen carefully for symptoms. We assess risk. We screen. We diagnose. We develop treatment plans. We teach coping strategies. We prescribe medication. We make referrals.

These are essential parts of good clinical care. But they can also create a clinical blind spot.

A mother says, “I can't sleep.”
We hear insomnia.

She says, “I'm anxious all the time.”
We hear anxiety.

She says, “I'm having thoughts that scare me.”
We assess intrusive thoughts.

She says, “I don't feel like myself.”
We assess depression.

Recognizing symptoms is not the same as understanding suffering. And in the perinatal period, that distinction can be clinically consequential.

When our attention becomes too focused on identifying and treating the symptom, we can miss the experience in which that symptom is embedded. We may accurately identify what is happening while still failing to understand what it feels like to be the woman experiencing it.

A mother can tell us what she is experiencing and still not disclose the full depth of her suffering. She may minimize it. She may struggle to find words for it. She may fear what will happen if she reveals it. She may not fully understand it herself. And so, she endures parts of it silently.

This is where we have to move beyond What are your symptoms? and ask a different kind of question:

How bad does this feel for you?

“I can't sleep.”

“The baby wakes me every two hours. I haven't slept because my brain won't stop. I'm terrified I'll never sleep again. Sometimes I think, why did I even have this baby? Then I feel so horrible for thinking that. I just want to go to sleep and never wake up.”

“I'm having scary thoughts.”

“I keep having images of something terrible happening to my baby. I don't want them. They terrify me, and I'm afraid that having them means there is something wrong with me.”

“I don't feel like myself.”

“I look in the mirror and don't recognize who I've become. I don't enjoy anything anymore. I feel disconnected from my baby, my partner, and everyone around me. I keep wondering if they're all better off without me.”

The symptom gives us an entry point. The suffering tells us what the symptom means. Our job isn't only to hear what a mother is telling us. It's to become curious about what her words are trying to tell us.

The Burden Cannot Be on the Person Who Is Suffering

Our mental healthcare system places an extraordinary amount of responsibility on the patient:

Tell us what is wrong.

Recognize when it is getting worse.

Call us if something changes.

Know when your thoughts have become concerning.

Ask for a higher level of care.

Advocate for yourself.

But the more seriously someone is struggling, the harder many of those tasks may become.This becomes particularly important when we think about severe mental illness and psychosis. Psychosis can affect insight—the person's ability to recognize that her perception of reality has changed.

Which is why we cannot rely on a maternal mental healthcare system that requires the sickest person in the room to also be the person responsible for recognizing the severity of her illness.

The responsibility has to extend beyond her. Family members need to know what changes to look for. Clinicians need to recognize when a presentation is shifting. Providers need mechanisms for communicating with one another. And our systems need to be able to respond when a woman cannot fully recognize or articulate the severity of what is happening to her.

“But She Said She Was Fine”

This is where our work becomes more complicated. A woman can tell us she is fine and still be suffering tremendously. She may minimize a symptom because she is frightened of what will happen if she discloses it. She may experience intrusive thoughts and believe they mean she is a terrible mother. She may appear highly functional while privately feeling as though she is unraveling. And someone experiencing psychosis may genuinely believe that what she is experiencing is real.

Her words matter.

But her words cannot be the only thing we are listening to.

There can be an additional expectation placed on women who are nurses, physicians, therapists, or other healthcare professionals:

She would know if something were really wrong.

But knowing the diagnostic criteria for an illness does not make someone immune to experiencing it. Professional knowledge does not guarantee insight when you become the patient.

In fact, that expectation can create another layer of shame:

I should know how to handle this.

We should also be careful not to mistake functioning for wellness. A woman may show up on time, care for her children, go to work, answer questions appropriately, or look completely put together while suffering profoundly underneath.

Sometimes appearing in control is precisely how someone manages the terror of feeling out of control.

Screening Is Important. But Screening Cannot Capture the Whole Story

We absolutely need screening in maternal healthcare. But a screening tool cannot sit with someone. A score cannot notice that something about today's conversation feels different from last week's. A questionnaire cannot hear hesitation. And the responses do not allow insight into the suffering.

Screening should open the door to assessment—not close it.

Our systems need to support clinicians in walking through that door. That means reassessment when the clinical picture changes, consultation when something does not fit, communication between providers, collateral information when appropriate, and escalation when the level of concern increases.

The goal is not to abandon screening. It is to remember what screening was designed to do, which is help us identify where we need to look more closely.

What the Lindsay Clancy Case Asks Us to Consider

This case has left many of us trying to understand how a mother could be receiving mental health treatment and still be suffering so profoundly. We may never know everything that happened inside each clinical encounter, and it would be unfair to assume that we do. But the case gives us an opportunity to think differently about what it means to care for a mother whose suffering is becoming increasingly difficult for her to understand, articulate, or manage.

What stays with me is not simply whether the right questions were asked or the right diagnosis was made at the right time. It is the larger question of whether our systems of care are equipped to recognize the depth of suffering when it doesn't present itself neatly. A woman may be seeking treatment, attending appointments, taking medication, answering our questions, and still not be able to communicate the entirety of what is happening inside of her.

That is what makes this work so complicated. We have to listen to what a mother tells us while remaining curious about what she may not yet have the words (or insight) to tell us. We have to believe her suffering without assuming that her description of it gives us the complete clinical picture.

The lesson I take from this case is not that every tragedy can be predicted or prevented. It is that we cannot become complacent simply because a mother is receiving treatment. Treatment is not the same as being understood. Screening is not the same as assessment. And access to care does not necessarily mean that the depth of someone's suffering has been fully recognized.

Perhaps that is where our responsibility as clinicians becomes most important: to stay curious when something doesn't quite fit, to reassess when symptoms change, to listen to the people who know her well, to consult when we are uncertain, and to resist placing the responsibility for recognizing deterioration entirely on the person who is deteriorating.

The Lindsay Clancy case cannot tell us exactly what happened in every room she entered. But it can challenge those of us who care for mothers to think more deeply about what happens in our own rooms.

To My Fellow Perinatal Clinicians

This is the idea I want clinicians, especially those of us working with perinatal populations, to internalize:

Listen for symptoms. But listen even harder for suffering.

When she tells you she is anxious, don't stop at anxiety. When she tells you she isn't sleeping, ask what those sleepless nights are actually like. When she says she is overwhelmed, understand what overwhelmed means in her life. Get to the suffering.

We have to be willing to sit in it with her.

When the words and the suffering seem mismatched, don't assume the suffering isn't there. And when you aren't sure, consult. Seek training. Get support.

Our job is to create enough safety, curiosity, time, and clinical awareness that a woman does not have to perfectly explain her suffering before we recognize how much she is hurting.

Because the burden of understanding maternal suffering should never rest entirely on the mother experiencing it.