This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with adults and new parents, an organised link with maternity and psychiatric teams, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is not written for the people concerned: if you are expecting a child or have just had one, and you are thinking of dying, no longer sleeping at all, or afraid for your baby's safety, contact your country's emergency services, your maternity unit or your doctor today.
1. The programme at a glance
Indication. A major depressive episode, an anxiety disorder — generalised anxiety, panic disorder, obsessive-compulsive disorder — or a mixed picture, beginning or continuing during pregnancy or in the year that follows birth, in the mother, the father or the co-parent, of mild to moderately severe intensity, once the emergencies of sections 3 and 4 have been ruled out.
Reference model. Two psychological treatments that have data in this period: cognitive behavioural therapy — activation and work on thoughts (Milgrom et al., 1999), exposure for intrusive thoughts (Abramowitz et al., 2003) — and interpersonal therapy adapted to the postpartum period, which targets the role transition, conflicts and support (Stuart and O'Hara, 1995; O'Hara et al., 2000). The protocol combines them, and adds two targets belonging to this period: sleep and the bond with the baby.
Format. Twelve individual sessions of 50 to 60 minutes, weekly, one of them with the partner or someone close. The baby may be present. Two booster sessions, at one month and at three months. The flexibility of the frame is part of the protocol: a session cancelled because the baby has a fever is rescheduled, it is not lost.
Target mechanism. To break the loops that maintain the disorder at this precise moment of life: the exhaustion that pulls mood down, the withdrawal that removes pleasure, the demand of the good mother that feeds guilt, the avoidance and the checking that maintain fear, and the isolation that makes asking impossible.
| Session |
Focus |
Session deliverable |
| 1 |
Assess, rule out the emergency, make safe |
Emergencies ruled out, baseline measures, worksheet 2 |
| 2 |
Understand and decide |
Written formulation, order of work chosen |
| 3 |
Nights and who takes over |
Written night plan, helpers named |
| 4 |
Getting a footing back in the day |
Three activities scheduled |
| 5 |
The mother one is supposed to be |
One rule examined and rewritten |
| 6 |
The thoughts that frighten |
One avoidance or one check dropped |
| 7 |
Session with the partner or someone close |
Written division of tasks, warning signs shared |
| 8 |
What has changed |
Losses and gains named, one resumption dated |
| 9 |
Asking, saying, arguing differently |
One request made, one conflict revisited |
| 10 |
The bond with the baby |
Two shared moments a day |
| 11 |
The birth: preparing it, or putting it back in its place |
Plan for the first weeks, or a narrative placed in time |
| 12 |
Review, relapse, and next time |
Written plan, measures repeated |
What the person takes away. Ten printable worksheets, listed in section 42: my record, my safety plan, my nights and who takes over, my days, what I tell myself, the thoughts that frighten, the partner's and relatives' corner, around me, my baby and me, my plan for what comes next.
What sets this programme apart from the other manuals on this site. Three things. The emergencies placed before everything else, with a whole section on how to tell an intrusive thought from an idea that puts the baby in danger. Sleep treated as an intervention, before the cognitive work. And the bond with the baby worked on for its own sake, because treating the parent's depression is not enough to improve it.
2. Before you start
Who this programme is written for
This text is written for psychologists, psychiatrists, psychotherapists, midwives and doctors trained in cognitive behavioural therapy, and if possible in interpersonal therapy. It assumes that you can assess suicide risk, that you know the emergency psychiatric pathway of your area and the nearest mother and baby unit if there is one, and that you can reach the maternity unit, the midwife or the doctor who is following the person.
It is written neither for the people concerned nor for those close to them.
The four decisions to make first
Is there an emergency? Postpartum psychosis, suicide risk, thoughts of dying with the baby, loss of control towards the baby: sections 3 and 4. These are the only questions that can interrupt the programme, and they come before any other.
Is this unipolar depression? After a birth, a notable proportion of women identified as depressed in fact have bipolar disorder (Wisner et al., 2013). The question of periods of elation, of a reduced need for sleep without tiredness, and of family history is asked of every person. Section 10.
Which is the main disorder? Depression, generalised anxiety, panic disorder, OCD, post-traumatic stress linked to the birth: they often coexist, and what dominates decides the emphasis of sessions 4 to 6 and 11.
Pregnancy or after the birth, and who is around? The protocol keeps the same components; its calendar, its pace and the place of the partner change. Section 35.
What this programme does not treat
It does not treat postpartum psychosis. That is a psychiatric emergency, calling for admission, ideally to a mother and baby unit. Section 3.
It does not treat bipolar disorder on its own. The work described here has its place there, but within a psychiatric framework, with a written perinatal plan and vigilance about sleep. See Bipolar disorder: psychoeducation and relapse prevention — a therapist's manual.
It does not on its own treat an established PTSD linked to the birth, nor a severe OCD. It identifies them, begins the work, and switches to the specific protocol when they dominate: Post-traumatic stress disorder in adults: a therapist's manual and Treating obsessive-compulsive disorder in adults: a therapist's manual.
It does not treat perinatal bereavement as a depression. Section 36.
And it does not replace medical, obstetric and paediatric follow-up, nor the decision about medication.
How to use it
Read the whole thing before the first session, in particular sections 3, 4, 12, 31 and 33: these are the five places where people go wrong. Each session follows the same frame: the aim, the steps, what you say, the common mistakes, and the criterion for moving on.
Three warnings belonging to this period.
The person will not say everything. The shame of not being happy, the fear of having her child taken away and the thoughts she finds monstrous silence what matters most. The way you ask, and the way you react to the answer, decides what she will say next.
Time counts. A baby is growing while the treatment waits. British guidance asks that a psychological intervention start within a month of the assessment (NICE, 2014).
And you are not working alone. Midwife, obstetrician, general practitioner, paediatrician, psychiatrist: the link is organised in the first session, with the person's agreement, and not at the moment of crisis.
3. Emergencies first: postpartum psychosis and suicide risk
Why this section is placed here
Because it describes the two situations in which a mother may die, or a baby be put in danger, in the days to come. The perinatal period increases the risk of severe psychiatric disorders (Jones et al., 2014). These situations are rare compared with perinatal depression. They are not to be missed.
Postpartum psychosis
What it is. A psychotic episode, most often affective in nature — manic, mixed, or depressive with psychotic features — which occurs after childbirth and is a psychiatric emergency, with a risk of suicide and of infanticide (Bergink et al., 2016). It begins abruptly, most often in the first weeks — British guidance asks for particular vigilance during the first two weeks in women at risk — and can worsen very quickly (NICE, 2014). It affects in the order of one to two women in a thousand who give birth (NICE, 2014; VanderKruik et al., 2017).
What you observe, or what those close to her report. Total insomnia, including when the baby is asleep, without any sense of tiredness. Agitation, elation, or a mood that changes from hour to hour. Perplexity, confusion, disjointed speech, a sense of strangeness. Delusional ideas, very often centred on the baby — that he is ill with something nobody can see, swapped, threatened, possessed, or promised a particular destiny. Hallucinations. Unusual behaviour that the partner sums up by saying: "this is not her any more".
What increases the risk. Bipolar disorder, a history of postpartum psychosis, and bipolar disorder or puerperal psychosis in a first-degree female relative. Among women at high risk, about a third relapse after the birth, and in women with bipolar disorder the risk is clearly higher without preventive treatment during pregnancy (Wesseloo et al., 2016). But postpartum psychosis also occurs in women with no psychiatric history at all (NICE, 2014).
What you do. A psychiatric assessment the same day: British guidance asks that it take place within four hours of referral (NICE, 2014). You telephone in front of the person and those with her, you do not let her leave on her own, and the mother is not left alone with the baby until the assessment has taken place. You say it to the partner in plain terms: "this is a medical emergency, it can be treated, and it is treated in hospital". Admission to a mother and baby unit, where that is possible, avoids separation.
What you do not do. Wait for the next session. Take the insomnia for the ordinary tiredness of a new mother. Conclude that this is the baby blues because it is the fourth day.
Before the birth, in a woman at risk. A written perinatal plan with the psychiatrist and the obstetric team: who monitors what in the first weeks, how sleep is protected, which number to call. It is the most useful intervention in this section, and it is done during pregnancy.
Maternal suicide risk
What has to be known. When they take in the whole year that follows the birth, confidential enquiries into maternal deaths place suicide as the leading cause of death: in the United Kingdom from the enquiry covering 1997-1999 onwards (Oates, 2003); in France in the national enquiry covering 2016-2018, where suicide and other psychiatric causes account for 17% of maternal deaths, the suicides occurring for the great majority after the first six weeks (Inserm and Santé publique France, 2024). In a British enquiry covering women in contact with psychiatric services, those who died by suicide during the perinatal period had, compared with those who died by suicide outside that period, more often a diagnosis of depression and less often active treatment at the time of death; they were also younger, more often married, and ill for a shorter time (Khalifeh et al., 2016). In other words, the profile does not always look like the one you expect.
What you do. You ask every person, from the first session onwards, and at every session for as long as mood is low. Directly, without euphemism: "Do you ever think that you would rather not be here any more?" then "Do you ever think about taking your own life?" The Edinburgh scale includes an item on thoughts of self-harm: read the answer at every administration, before working out the score.
The question that is added in this period. "When you think about dying, what do you imagine for the baby?" An answer of the kind "he would be better off without me" calls for a safety plan. An answer of the kind "I could not leave him" or "we would go together" is an absolute emergency: section 4.
What is put in place. A written safety plan, with the person and, when she agrees to it, with her partner (Stanley and Brown, 2012); restricting access to means, entrusted to a named third party; the modifiable factors — insomnia, isolation, pain, alcohol, conflict, violence — treated as targets; and close contact, because a person who misses an appointment in this period is called the same day. The detailed approach is that of Suicidal behaviour in adults: a therapist's manual.
What you must have ready before the first session
The number of the emergency psychiatric service of your area, that of the maternity unit, the contact details of the nearest mother and baby unit, your country's child protection procedure, a blank safety plan, and the answer to this question: what do you do if a mother tells you, on a Friday at ten to seven in the evening, that she has thought about dying with her baby?
4. Thoughts of harming the baby, and protecting the infant
Why a whole section
Because two opposite mistakes do the most damage here. Making light of it: hearing "I am afraid of harming him" and answering "all mothers think that", having assessed nothing. Taking alarm: hearing the same sentence and setting off a child protection procedure against a mother who, in the very great majority of cases, is no danger at all to her child, and who will never say anything to anyone again.
What research establishes
These thoughts are common. In a study that followed a hundred women from pregnancy to the third month after the birth, all of them reported intrusive thoughts of accidental harm to the baby, and nearly half unwanted thoughts of harming him intentionally. The latter occurred more often in mothers who reported high parenting stress and low social support, and the study found hardly any link between these thoughts and aggressive parenting behaviour (Fairbrother and Woody, 2008).
OCD is more common in this period than in the general population (Russell et al., 2013), and its obsessions typically concern harm done to the baby (Abramowitz et al., 2003).
An obsession is different from a delusional idea. The obsession is experienced as absurd and contrary to what the person is, it frightens, it leads to avoidance and rituals, and it does not come with an increased risk of acting; the idea of harming the baby within a psychosis is on the contrary in keeping with the delusion, without fear or ritual, amid other psychotic signs, and it does come with an increased risk of aggressive behaviour (Abramowitz et al., 2003).
And the thought is not the problem. What makes it a disorder is the meaning given to it — "if I think it, that means I could do it", "a good mother would never have that idea" — and what is then done to neutralise it (Abramowitz et al., 2003).
Four phenomena to tell apart
1. The intrusive thought, anxious or obsessional. An image or an idea that springs up — the baby falling down the stairs, the knife, the bath, suffocation — experienced with horror, contrary to everything the person wants, and followed by avoidance — no longer giving the bath, putting the knives away, never being alone with him — by checking and by requests for reassurance. The person speaks of it, when she dares, because she is afraid of herself. This is not a danger to the baby. It is suffering, and it can be treated: section 31 and session 6.
2. The psychotic idea. A conviction rather than an intrusion: the baby is threatened, possessed, ill, not hers, or must be taken away from a danger nobody else can see; sometimes a voice that commands. The idea is not experienced with horror but as self-evident, often in a context of insomnia, confusion or elation, and it can be concealed. This is an emergency: section 3.
3. The depressive idea of shared death. In a severe depression, the thought of dying extends to the child: "I cannot leave him in this world", "he will suffer less with me". It is not experienced as alien but as the logical conclusion of despair. This is an absolute emergency, in the same way as a suicide plan with a means available.
4. Anger and loss of control. Not an image that horrifies, but an impulse that rises when the baby cries and exhaustion is at its peak: the urge to shake him, to make him stop, a rough gesture already made or almost made. The person is ashamed of it, and rarely speaks of it. This is a real risk, which is dealt with through concrete safety and support, and which may call for protection.
The questions that tell them apart
"When that thought comes to you, what do you feel?" Horror and disgust point towards the intrusive thought; indifference or self-evidence, towards a psychotic or depressive idea.
"What do you do next?" Avoiding, checking, seeking reassurance: that is the signature of anxiety and OCD.
"In that thought, does harming the baby seem to you a good thing, or a necessary thing?" Any positive answer takes this out of the field of the intrusive thought.
"Do you have the impression that strange things are happening, that someone means you harm or means harm to the baby? Do you hear voices?"
"When the baby sleeps, do you sleep?" An inability to sleep, without tiredness, points towards section 3.
"When you think about dying, what do you imagine for him?"
"Has it ever happened that you were afraid of losing control when he cries, or that you made a gesture you regret?"
And, with the person's agreement, what the partner has observed: sleep, behaviour, recent changes.
What you say when it is an intrusive thought
"Many parents have exactly this kind of thought, and many do not dare speak of it. What you are describing to me — that the idea horrifies you, that you do everything to avoid it — is what people do who are afraid of doing harm, not those who intend it. This is not a danger to your baby. It is suffering for you, and it can be treated."
That sentence is said after the assessment, never in its place.
Protecting the infant
When it becomes the priority. A psychotic idea concerning the baby, an idea of shared death, a violent gesture already made, serious neglect — the baby is no longer fed, changed, or shown to the doctor — or violence in the home to which he is exposed.
What you do. You organise immediate safety — a reliable adult present, a medical assessment the same day, examination of the baby by a doctor if a gesture has taken place — and you apply the child protection procedure laid down by the law of your country. You tell the person what you are doing and why, unless that increases the danger. Most often, protecting the child and caring for the parent point in the same direction, and saying so changes what follows.
What is prepared with all parents, whatever the picture: what to do when the crying becomes unbearable. Put the baby on his back in his cot, leave the room, breathe, call somebody, come back when you are calm. A baby crying in a safe cot is in no danger; a baby who is shaken is. This is set out on worksheet 2.
What you do not do
Reassure without assessing.
Report on the strength of an intrusive thought alone, experienced with horror, with no other element. The mistake is common, its damage is lasting, and it teaches the person to say nothing ever again.
Advise her never to be alone with the baby when it is an intrusive thought: that confirms the fear. The same advice is essential in the face of a psychotic idea or an idea of shared death. Hence the assessment first — and again at the following sessions, because a picture can change within a few days.
5. The pictures not to be confused
1. The baby blues
What you observe. In the first days after the birth, ready tears, a labile mood, irritability, heightened sensitivity, tiredness. It is very common.
What points to it. It is brief, fluctuating, compatible with moments of joy, and it goes away on its own, usually within a few days. Symptoms that persist beyond two weeks call for an assessment.
What it implies. Information, sleep, support, and a check at two weeks. No treatment. But total insomnia, perplexity or strange ideas on the fifth day are not the baby blues: section 3.
2. Perinatal depression
What you observe. Low mood or loss of pleasure lasting beyond two weeks, guilt often centred on being a bad parent, a sense of being unable, withdrawal, despair, sometimes thoughts of death. It often begins during pregnancy.
What it implies. This is the heart of this programme.
3. Perinatal anxiety disorders and OCD
What you observe. Permanent worry, often centred on the baby's health; panic attacks; intrusive thoughts of harming the baby followed by avoidance and checking; repeated checking of his breathing at night.
What points to it. Anxiety dominates and mood is preserved, or else the two coexist.
What it implies. The same programme, with session 6 reinforced and, if OCD dominates, a switch to the specific protocol.
4. Post-traumatic stress linked to the birth
What you observe. Images of the birth that come back, nightmares, avoidance of the maternity unit, of the subject, sometimes of the baby who recalls it, hypervigilance.
What it implies. Section 34, and the specific protocol if it is established.
5. Postpartum psychosis and the bipolar episode
Section 3.
6. Exhaustion and difficult adjustment
What you observe. Extreme tiredness, irritability, tears, in a context of broken nights, of a baby hard to console or of a lack of help — but pleasure comes back as soon as the person sleeps and somebody takes over.
What it implies. Support, relief, sleep, and a reassessment. If it does not give way when sleep comes back, it was not only exhaustion.
The three sorting questions
"Are there still moments of pleasure, with the baby or elsewhere?" It separates exhaustion from depression.
"What frightens you most, and what do you do so as not to think about it?" It isolates anxiety and OCD.
"When the baby sleeps, do you sleep?" It picks out psychosis and hypomania.