“If you’re having thoughts of harming yourself or your baby, go to the nearest emergency room.”

Sound familiar?

That’s because this is what every new mother and partner is told when they’re being discharged from the hospital with their new baby. This is typically the only piece of information that they walk away with regarding what to do in the case of a postpartum mental health crisis along with, perhaps, a handout on “baby blues” which is usually buried amidst a massive (and overwhelming) stack of papers.

And though sometimes these thoughts can be an emergency, many times, they are not. This post will hopefully help readers try to understand the difference.

In more rare cases when these thoughts are related to psychosis, it is indeed a 911 emergency. However, most times it is a scary intrusive thought, and I’m here to argue that there may be alternatives to an ER visit. Intrusive thoughts during pregnancy and postpartum are very common and very treatable with the right support. You are not alone.

So what happens if a new mother experiences a thought of harming herself and/or her baby and, as she’s been instructed, she works up the courage to tell her partner or a loved one, leaves her baby behind in the care of someone else, and gets herself to the nearest Emergency Room? I know firsthand what happens, but I was curious to see what the ERs themselves had to say about it.

I called five of the largest, most well-established Emergency Rooms in New York City to ask. “What is the emergency room protocol for a mother who admits herself to the ER expressing concerns of harming herself or her baby?” I asked. The discomfort on the other end of the line was palpable. Each person transferred me from department to department, hurriedly trying to get rid of me and my uncomfortable questions, or they simply hung up on me. Not one hospital was able to share with me this information.

Well, I will tell you, at least in my experience, there is no protocol. Here’s how it went for me. In 2019, when I followed the famous instructions of going to the nearest emergency room (Brooklyn Hospital Center) because I was experiencing intrusive thoughts of harming my new baby one week after giving birth to her, I waited in triage for 24 hours in a state of mental health crisis. I had not slept in five days because of the anxiety that the thoughts were giving me. Eventually, I was treated for preeclampsia, a medical condition that I did not have. My high blood pressure reading came from my state of crisis, not preeclampsia. But, in the entirety of Brooklyn Hospital, there was not one mental health professional available to speak with me or assess me. Not a social worker. Not a therapist. Not a psychiatrist. I’ll never forget the shift change that happened as I lay in triage hallucinating from my sleep deprivation and screaming for help. People were milling about with coffee while my world fell apart. At one point, a slew of med students shuffled by, stopping in front of me to peer at me from the other side of their notebooks. They watched my distress, the panic in my eyes, curiously, wondering if perhaps they’d chosen the wrong profession or at the very least making a mental note to switch to a different rotation.

If a new mother is separated from her baby in the wild, she exhibits signs of acute distress, agitation, and grief and will fight to the death to be reunited. This was me. A zoo creature, trapped in the ER, with no help in sight. So why are new mothers, or anyone in mental health crisis for that matter, told to go to the ER when many ERs are not equipped with any sort of mental health support, let alone the specialized treatment that a new mother in mental health crisis needs? Why is it that even though 1 in 5 women experience some sort of mental health challenge during pregnancy and postpartum, the sad measly instructions we’re given is to separate ourselves from our new baby and join the slews of forgotten patients in triage?

Four years later as part of my Masters in clinical mental health counseling, I am working on an assessment protocol for clinicians to follow when they are treating a new mother who is experiencing a Perinatal Mood and Anxiety Disorder (PMAD). One of my areas of focus has been collecting information on how to help guide clinicians on how to assess risk when a new mother is experiencing thoughts of harming herself or her baby which I’ve shared below.

With accurate psychoeducation as well as open discussion on this topic, I believe that together we can reduce the fear, silence, and suffering that mothers often endure (alone!) when experiencing these types of thoughts. In my own treatment of my OCD symptoms, the most effective coping strategy has been to identify, name, and label these thoughts as intrusive and separate from me. This takes the wind out of their sails so to speak and reduces their power (even more so when they are said out loud!)

• If you experience thoughts of harming yourself or your baby during pregnancy and/or postpartum you are likely experiencing an incredibly treatable and common symptom of a mood and anxiety disorder

• It is not your fault

• You are not alone

• I know it is scary, but tell someone, preferably a trusted support person or perinatal mental health specialist, silence increases fear and the power of the thoughts

• If being in a hospital feels safer than being at home, trust your gut and go but arm yourself with knowledge and other resources to reach out to along the way

• If you are a support person deciding whether or not to take a new mom in mental health crisis to the ER, you can follow the below risk assessment to determine if the thoughts are indeed a 911 emergency. If an ER visit is needed, try, if at all possible to choose one that has a mental health professional on staff or an affiliated psychiatric hospital onsite or nearby (ideally with a perinatal mental health unit).

Risk Assessment

• Low-risk thoughts (usually associated with Postpartum OCD)

  • Accompanied by good insight and awareness of the thoughts - a sense of separation between the intentions of self and the thoughts

  • Are not generally accompanied by psychotic symptoms (i.e auditory or visual hallucinations - though these can exist in cases of OCD accompanied by severe sleep deprivation)

  • The thoughts cause significant anxiety and/or distress

  • The thoughts are ego-dystonic, meaning the individual does not want these thoughts

  • The thoughts cause avoidant behaviors in relation to the thoughts (i.e. “if they have experienced thoughts of drowning their baby, they will avoid giving the baby a bath”)

• Treatment for low-risk thoughts (usually associated with Postpartum OCD)

  • Provide reassurance and psychoeducation - i.e. “intrusive thoughts are very common, this is a symptom, not an intention, etc

  • Label and identify intrusive thoughts as intrusive thoughts - labeling creates space and reduces distress

  • Provide psychoeducation and basic self-soothing and distress tolerance skills for managing anxiety associated with the thoughts

  • Refer to a reproductive psychiatrist to provide medication for reducing these symptoms

• High-risk thoughts (usually associated with Postpartum Psychosis and/or Bipolar disorder)

  • Accompanied by poor insight and lack of awareness of thoughts/intentions

  • Accompanied by Psychotic symptoms (delusional beliefs, distortion of reality, hallucinations, disorganized thinking, paranoia)

  • The thoughts do not generally cause anxiety or distress and are expressed by the client as plausible/inevitable actions or outcomes

  • This is a 911 emergency

• Treatment for high-risk thoughts (usually associated with Postpartum Psychosis and/or Bipolar disorder)

  • Calling emergency services/911 and/or assisting with admitting to an inpatient psychiatric hospital (ideally one with perinatal mental health services or specialties - though these are unfortunately few and far between in the U.S.)

  • Positively reinforcing patient honesty so that you can gather data and information about their internal experience

  • Do not leave mother and baby unattended (but continue to provide an atmosphere of positive regard and support)

  • This is a 911 emergency

My Personal Intrusive Thought Protocol

• Identify the thought and label it. “I’m having an intrusive thought”.

• Remind yourself that the thought is a symptom.

• Say the thought out loud to a trusted support person or trained perinatal mental health clinician.

• Do not suffer in silence.

• Remember that these thoughts are temporary. With treatment, they will improve.

• If your thoughts seem to be running on a loop, get up and do something. (Exercise, make tea, take deep breaths, do the dishes)

• Try not to resist the thoughts or make them go away, instead, accept that they are there, firmly label them, and move on with what you are doing.

• Treat it like a bothersome fly, it is annoying, but it can’t hurt you, or anybody else. Brush it off.

• Catch up on sleep, nutrition, and exercise.

• Go to therapy (preferably someone with a PMH-C and/or see a reproductive psychiatrist.

Further Reading

• Good Moms Have Scary Thoughts: A Healing Guide to the Secret Fears of New Mothers

• What I Want All Parents to Know About Postpartum Mental Health by Rebecca Feldman

• Risk Assessment: Thoughts of Suicide or Harm to Baby

• Postpartum Support International on Postpartum OCD

• Postpartum Support International on Postpartum Psychosis

Disclaimer: This blog post represents my opinion alone based on my lived experience. It should not be treated as medical advice and if you are struggling it is important to reach out to a licensed mental health professional.