Aug 12, 2026
Content note: This blog discusses severe postpartum mental illness and the Lindsay Clancy criminal trial. It is intended to explore broader questions about clinical competence and scope of practice, not to determine responsibility for the events at issue in the trial or evaluate the professional conduct of any individual health-care provider.
The ongoing Lindsay Clancy trial in Massachusetts has prompted difficult conversations about postpartum mental health, psychiatric treatment, access to specialized services, and the challenges clinicians face when assessing complex or evolving psychiatric presentations. It has also brought renewed attention to a principle that is fundamental to ethical mental health care: working within one's scope of practice and, just as importantly, one's individual scope of competence.
For therapists, understanding scope involves more than knowing what our professional designation legally permits us to do. It also requires us to consider whether our education, specialized training, clinical experience, supervision and ongoing professional development have adequately prepared us to provide a particular service to a particular client.
At VOX Mental Health, we take this distinction seriously. We do not believe therapists can, or should, attempt to treat every mental health presentation simply because it falls broadly under the umbrella of psychotherapy.
Sometimes competent care means providing treatment ourselves. Sometimes it means consulting with another professional, coordinating care, recommending a specialized assessment, or referring the client elsewhere... Knowing where our expertise ends is part of clinical competence.
The Clancy case concerns a Massachusetts mother who is currently on trial following the deaths of her three children in January 2023. Her defence has argued that severe mental illness, including alleged postpartum psychosis, affected her criminal responsibility, while prosecutors have challenged aspects of that account. Those legal questions ultimately belong to the court.
As part of the trial, considerable attention has been directed toward the mental health treatment Clancy received before the deaths, including hospitalization, outpatient psychiatric care, medication management, telehealth appointments, and the symptoms she did or did not report to clinicians.
The defence has scrutinized aspects of that care, including questions about clinical experience with postpartum psychosis. At the same time, treating clinicians have testified about what they observed, what Clancy reported to them, and why particular diagnoses were or were not made based on the information available at the time.
That last point is important.
There is a significant difference between examining a case retrospectively and making clinical decisions in real time.
Once a devastating outcome is known, earlier information can take on a different meaning. Clinicians working in real time do not know what will happen next. They must make decisions using the information available to them at that moment: reported symptoms, observed presentation, history, collateral information where available, assessment and professional judgment.
For that reason, this case should not be reduced to a claim that a particular clinician "missed" something, practised outside their competence, or could necessarily have prevented what occurred. Those conclusions have not been established, and it would be inappropriate to make them based on reporting from an ongoing trial.
Instead, the case provides an opportunity to consider a question relevant to every mental health professional:
How do we recognize when a client's needs have moved beyond our own expertise?
This distinction is central to responsible clinical practice.
A regulated professional may have a relatively broad legal scope of practice while possessing much narrower areas of individual competence. In Ontario, for example, registered social workers may provide psychotherapy and other clinical services within the scope of social work practice. BUT- that does not mean every registered social worker is competent to treat every presentation that may arrive in a psychotherapy office.
The Ontario College of Social Workers and Social Service Workers requires registrants to understand the extent and parameters of their competence and professional scope and to limit their practice accordingly. When developing competence in a new area, clinicians are expected to obtain appropriate education, consultation, supervision or other preparation.
Put simply:
"I am qualified to provide psychotherapy" does not automatically mean "I am qualified to treat this particular presentation."
This distinction makes intuitive sense in other areas of health care. We do not expect every physician to possess the expertise of a cardiologist, neurologist, oncologist and obstetrician simply because all are physicians. Mental health care is no different.
Mental health encompasses an enormous range of clinical presentations, and expertise in one area does not automatically translate into expertise in another.
A therapist may be highly experienced in trauma treatment but have limited specialized training in eating disorders. A couples therapist may have years of advanced relationship training but little experience treating obsessive-compulsive disorder. A clinician may be exceptionally competent in treating anxiety and depression while recognizing that emerging symptoms require psychiatric assessment or another level of care.
Specialized knowledge may be required when working with presentations involving:
- eating disorders;
- obsessive-compulsive disorder;
- psychosis;
- complex dissociation;
- substance-use disorders;
- severe and persistent mental illness;
- complex trauma;
- intimate partner violence;
- perinatal mental health; or
- other conditions requiring specialized assessment or intervention.
There can certainly be overlap among these areas. However, they are not interchangeable simply because they all involve mental health. Clinical competence should not be measured by how many conditions a therapist is willing to put on a website. In some circumstances, competence is demonstrated by recognizing when not to take the referral.
The public discussion surrounding the Clancy case also demonstrates why specialization within a broad category such as "postpartum mental health" matters.
Perinatal mental health encompasses experiences that can differ significantly in their presentation, severity and required treatment. Supporting someone experiencing adjustment difficulties or postpartum anxiety is not necessarily clinically equivalent to assessing or treating a severe or rapidly changing psychiatric presentation.
Depending on the person's needs, appropriate care might involve:
- psychotherapy;
- primary medical care;
- psychiatric assessment;
- medication management;
- a specialized perinatal mental health program;
- hospital-based intervention; or
- coordinated multidisciplinary treatment.
Postpartum psychosis, specifically, is rare and is considered a psychiatric emergency requiring urgent assessment. A general mental health practitioner may encounter it very infrequently, if at all, during their career. This does not mean that every postpartum client requires specialist psychiatric treatment, nor does it mean that general mental health professionals cannot competently provide perinatal support.
It means clinicians must be able to recognize when the presentation in front of them requires something different.
The question is not simply:
"Does this fall under mental health?"
The better question is:
"Do I have the appropriate training and competence to provide the level of care this person currently requires?"
There can be an uncomfortable assumption in psychotherapy that referring a client elsewhere means the therapist has somehow failed.
We disagree.
Therapists naturally want to help the people with whom they work, particularly once a meaningful therapeutic relationship has developed. A clinician may worry that suggesting another provider will feel rejecting or that the client will interpret a referral as abandonment.
In private practice, there can also be another uncomfortable reality: retaining a client has financial value.
We cannot say this strong enough: neither of those considerations should determine clinical care. When a client's needs exceed a therapist's competence, several options may be appropriate. The clinician might seek consultation or supervision, recommend an assessment from another professional, collaborate with a physician or psychiatrist, refer one component of treatment to a specialist, or recommend transferring care entirely.
Referral does not necessarily mean ending therapy.
Sometimes it means expanding the treatment team.
The objective should never be to keep the client on our caseload at all costs. The objective is to help the client access the care that best meets their needs.
Scope of competence is also not something that can be assessed once during intake and then forgotten. A client may initially present with concerns that comfortably fall within a therapist's expertise. As treatment progresses, however, new information may emerge. Symptoms can intensify, risk can change, or a seemingly straightforward concern can reveal a level of complexity that requires specialized care.
For example:
- an eating concern may develop into a presentation requiring specialized eating-disorder treatment;
- substance use may become increasingly problematic;
- trauma treatment may reveal significant dissociation;
- symptoms initially understood as anxiety or depression may begin to warrant psychiatric assessment; or
- a postpartum client's presentation may change in a way that requires urgent medical or psychiatric involvement.
The fact that a therapist was an appropriate provider at the beginning of treatment does not necessarily mean they will remain the only or most appropriate provider throughout treatment.
Responsible practice therefore requires clinicians to continue asking:
Am I still the right person to provide this care?
Complex mental health presentations also challenge the idea that one clinician should be expected to meet every need. Psychotherapists, social workers, psychologists, family physicians, psychiatrists, nurses, specialized treatment programs and hospital-based services have different roles within the mental health system. A therapist may have frequent contact with a client while a psychiatrist has specialized diagnostic and pharmacological expertise. A physician may identify a medical contributor to psychiatric symptoms. Family members may observe changes that are not apparent during a scheduled appointment.
Each person may hold a different piece of the clinical picture.
For some clients, therefore, responsible treatment is not about identifying the one professional who should provide care.
Consultation and collaboration should not be interpreted as evidence that a clinician lacks competence. Knowing when additional expertise is required is itself an important clinical skill.
At VOX Mental Health, our team is intentionally composed of clinicians with different areas of education, training, experience and specialization.
We do not expect every therapist to treat every client who contacts us.
Our intake process is therefore about more than asking:
"Who has an opening?"
We also consider:
What is the client seeking support for?
What training and experience does the clinician have in that area?
Is specialized treatment indicated?
Are there needs that require another professional or service?
Is VOX actually the appropriate place to provide this care?
Sometimes another clinician on our team has the relevant specialization, which allows us to refer internally. Sometimes they don't. When we do not have the appropriate expertise within our practice, we refer out.
We would rather help someone access appropriate care elsewhere than retain a client whose needs exceed what we can responsibly provide.
The Lindsay Clancy case is extraordinarily complex, and it would be inappropriate to reduce it to a simple lesson about one clinician, one diagnosis, one medication decision or one moment when someone supposedly should have known what would eventually occur. Truly a tragedy in every sense.
The trial involves competing interpretations of Clancy's mental state, what information was available to clinicians at different points in time, and the treatment she received. Those questions deserve the nuance appropriate to an ongoing legal proceeding.
The broader professional conversation, however, extends far beyond this particular case.
Mental health professionals work with people whose symptoms can change, whose needs do not always fit neatly into diagnostic categories, and whose presentations may eventually extend beyond the expertise of the clinician they originally sought for support.
At VOX, we believe responsible clinical practice includes:
- developing meaningful areas of specialization rather than claiming expertise in everything;
- maintaining competence through continuing education, consultation and supervision;
- reassessing whether the treatment being provided continues to meet the client's needs;
- collaborating with other health-care professionals when appropriate;
- recognizing when a higher or different level of care is required; and
- referring internally or externally when another clinician is better equipped to provide that care.
None of those things make someone a le
Our responsibility is not to demonstrate that we can treat every person who enters our practice. It is to understand what the person in front of us needs, determine whether we have the competence required to provide it, and, when we do not, help connect them with someone who does.
Sometimes, the most responsible clinical decision is not to provide more treatment ourselves.
It is recognizing when the right treatment needs to come from somewhere else.
