Mothers commonly experience non-acted out thoughts and feelings that are perhaps indicative of more or less conscious murderous rage towards their infants. In my training as a psychodynamic psychotherapist I have experienced difficulties in finding a way to remain with a mother’s experience of murderous rage towards her infant, in the context of both the need to ensure the safety of the infant and the mother’s fear of losing her baby. Two frequent clinical approaches to such thoughts can be identified in the literature, based in the defensive positions of devaluation and idealisation. However, if thoughts and feelings of murderous rage are understood as normative there may be a third, integrative position available for clinical practice, bringing the devaluing and idealising clinical stances together in synthesis. This research is a hermeneutic literature review. I have identified three key emergent and sequential themes: maternal ambivalence; idealisation and devaluation; and fear and anxiety. I have come to understand the dominant clinical stances as influenced by both the mother’s presentation and the clinician’s incorporation and use of primitive psychic defences operating in the socio-cultural and organisational realms. I have further explored how our clinical attitudes can evolve developmentally from the defensive positions of idealisation and devaluation towards more capacity for thought and for thinking about. I now comprehend that this will require the clinician to confront their own omnipotence, to allow them to stay with their own vulnerabilities and with the vulnerabilities of their patients. This research is of particular relevance to improved understandings of both preventative and early intervention clinical approaches, with the potential to contribute to a decrease in maternal distress and a reduction in the negative impacts on infant development.