Applied behavior analysis (ABA): Techniques and how it works
Psychosis is a mental health crisis where someone loses “contact with reality.”
Postpartum psychosis is a severe and acute mental health episode that can happen to individuals after giving birth. It occurs in every one to two out of 1,000 deliveries, according to Massachusetts General Hospital’s Center for Women’s Mental Health.
Postpartum psychosis can last between two and 12 weeks, and it can take up to 12 months to fully recover, according to the National Health Service in the United Kingdom.
Postpartum psychosis examples that reach the news are the exception, not the rule—but they're a reminder of what's at stake. Untreated postpartum psychosis and postpartum depression can lead to outcomes that are severe, life-altering, and in some cases, fatal.
As mental health clinicians, it is our professional and ethical duty to prepare for clients seeking treatment for perinatal mood disorders and postpartum psychosis as we increase our collective understanding of these disorders and their impacts.
What are postpartum psychosis symptoms?
When a client experiences psychosis, they experience a break from reality. The thoughts, feelings, and emotions that they experience feel like reality to them but do not make sense to those around them.
This experience can be isolating and terrifying for the client, as well as potentially dangerous to the client and their family, as we’ve seen cases of postpartum psychosis result in suicide, homicide, and infanticide.
Symptoms of postpartum psychosis include:
Insomnia or a complete inability to sleep
Increased energy
Becoming confused or disoriented
Severe mood swings
Hallucinations
Delusional beliefs
Experiencing frightening, confusing, or unusual thoughts about themselves, their baby, or the world around them
Feeling intensely connected to spiritual, religious, or symbolic experiences
Difficulty distinguishing between dreams, thoughts, and reality
Paranoia
What are the causes and risk factors for postpartum psychosis?
The causes of postpartum psychosis are not widely understood, although there are risk factors to developing any perinatal mood disorder that providers who give care to postpartum parents should keep in mind.
During intake sessions with new clients, make sure that you assess the following:
Psychiatric history
Ask about previous mental health diagnoses, medications, or acute mental health episodes.
Ensure that you know if your client is taking medication and who is prescribing that medication, and ask your client to sign a release of information for you to be in communication with their medication providers as appropriate.
Psychosocial stressors
Encourage your client to identify any familial or social supports, disconnections, or estrangements.
Identify relationships that have the potential to fracture or crack during postpartum, as well as relationships that can offer structure in a difficult time.
Biological stressors
Inquire about family history of mental illness, family history of physical illness, and personal history of physical illness.
Take this time during intake to provide psychoeducation regarding the impact of hormonal fluctuations and sleep deprivation after giving birth.
Trauma history
While exploring your client’s trauma history, the ACE questionnaire is a great place to start. This is by no means an exhaustive list of traumatic experiences, but it is helpful in beginning to identify major stressful life events.
As a trauma therapist, I also use the Dissociative Experiences Scale – II to evaluate trauma related symptoms that may not be immediately apparent by the ACE results.
How do you assess safety in postpartum psychosis treatment?
When assessing safety in postpartum psychosis treatment, ask direct questions, including:
Do you have thoughts of harming yourself or anyone else?
Do you ever think about killing yourself or anyone else?
Do you have a plan to kill or harm yourself or anyone else?
Do you have access to lethal methods to harm yourself or anyone else?
Do you ever see things that other people do not see?
Do you ever hear things that other people do not hear?
If you find resistance in answering these questions due to stigma or shame, some clients may respond well with their provider beginning the safety assessment with questions such as:
Do you feel safe in your body?
Are you in control of your behavior?
Will you be safe in your body until the next time that we meet?
How do you create a safety plan for a client?
Safety planning is an important part of working with clients experiencing postpartum psychosis, suicidal ideation, or any other potentially unsafe thoughts and behaviors.
A safety plan will help a client to know their options in an emergency. Some questions to include when safety planning with postpartum psychosis clients are:
What makes your symptoms worse?
When treating a client with postpartum depression or postpartum psychosis symptoms, review people, places, activities, and situations that are particularly triggering or upsetting for your client.
What will distract you from unsafe thoughts?
Distractions help your client create space between a distressing thought and an unsafe action when experiencing postpartum psychosis symptoms.
What will help you calm down when you’re upset?
With high-acuity postpartum psychosis clients, frequently review, introduce, and practice coping and regulation skills in your sessions. Assign these skills as homework between postpartum psychosis treatment sessions and follow up to explore successes and barriers.
How do you know it’s time to get more help?
It is important to help clients experiencing postpartum depression or postpartum psychosis symptoms distinguish between distressing thoughts and unsafe behaviors.
Work with your postpartum psychosis client to understand their own boundaries around these thoughts and behaviors by identifying clear moments where they know they are no longer in control of their behavior due to an acute mental health episode.
Where do you go in an emergency?
Ensure that your postpartum psychosis client knows the names, numbers, and locations of local crisis centers, emergency rooms, and first responders to go to when experiencing severe postpartum psychosis symptoms.
How do counselors work with medication providers for postpartum psychosis treatment?
Postpartum psychosis should be treated by an interdisciplinary team. When working with perinatal mood disorders, the first step to this is to know who your client’s medication providers are, including their primary care physician, psychiatrist, or OBGYN.
As a counselor, you can help clients keep track of postpartum psychosis symptoms and changes to mood, sleep, or behavior that may coincide with medication changes, as you will most likely see your client the most often of any interdisciplinary team member.
During intake, have your postpartum psychosis clients sign a release of information between you and their other providers to ethically communicate about the client’s care.
Follow up with postpartum psychosis treatment providers to establish a relationship, as well as if you notice any changes to the client’s presentation, especially as it may be related to their medications.
Conclusion
Postpartum psychosis is rare, but when it happens, it moves fast and the stakes are high. The counselors best equipped to help are the ones who ask direct questions early, have a safety plan in place before a crisis hits, and stay in close contact with a client's medical team throughout treatment.
With the right support, recovery is not just possible—it's the most common outcome. Consultation, ongoing education, and a willingness to ask the uncomfortable questions are what make that recovery possible for the clients who need it most.
Sources
Alford, A. Y., Riggins, A. D., Chopak-Foss, J., Cowan, L. T., Nwaonumah, E. C., et al. (2025). A systematic review of postpartum psychosis resulting in infanticide: Missed opportunities in screening, diagnosis, and treatment. Archive of Women’s Mental Health.
The International Society for Psychological and Social Approaches to Psychosis. (n.d.) Postpartum psychosis: Understanding, recovery, and hope.
Massachusetts General Hospital Postpartum Psychosis Project. (2020). New research: Identifying the pathophysiology of postpartum psychosis.
MGH Center for Women’s Mental Health (2009). Can we identify women at high risk for postpartum psychosis?
National Health Service. (n.d.) Postpartum psychosis.
National Institute of Mental Health. (n.d.). Understanding psychosis.
The University of North Carolina School of Medicine. (n.d). Perinatal mood and anxiety disorders.
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