For some women with schizophrenia, adapting emotionally to pregnancy and motherhood is a struggle. Women with schizophrenia may have difficulty acknowledging and accepting the pregnant state, accurately interpreting the physical changes brought on by pregnancy, accepting prenatal care, managing pregnancy-linked anxieties, forming a reality-based attachment to the fetus, and grieving prior custody loss. Flexible psychotherapy, in which the therapist alters pacing, role and modality based on evolving developmental needs as pregnancy progresses, can be a useful adjunct to pharmacotherapy and psychosocial rehabilitation. This article uses composite case examples to illustrate the use of short-term psychotherapeutic strategies for women with schizophrenia during pregnancy, incorporating elements of cognitive-behavioral therapy, motivational interviewing, social skills training and family systems intervention. The article additionally describes assessment for psychotherapy, and the unique challenges of forming a therapeutic alliance when a therapist feels responsible for the patients fetus as well as for the patient.