Rosa Delgado

Referred by her GP, who has seen her four times for insomnia. The letter says "bereavement, not settling". Rosa arrives on time, apologises twice in the first minute, and says she is not sure she should be taking up a place.

Her mother died nineteen months ago of pancreatic cancer, eleven weeks from diagnosis. Rosa was her main carer during those weeks, having taken unpaid leave. She was not present at the moment of death; she had gone home to shower, at her brother’s insistence, and her mother died in the forty minutes she was away.

Since then: she sleeps four to five hours, has kept her mother’s flat exactly as it was and visits twice a week, and has not returned to the choir she sang in for eleven years. She has declined three invitations from friends in the past month. She works, competently, and describes school as "the only place I’m normal".

She cries readily when she speaks about her mother, and says she does not talk about her to anyone because "people have been very kind and I think they’d like me to be better now". Her brother has cleared his own grief, in her account, "very efficiently", and they have not spoken properly in a year.

Is this pathological?

Nineteen months of intense grief is not, by itself, disordered. The features that warrant treatment here are functional: sustained avoidance of reminders that would allow mourning to proceed, preservation of the environment as if the death had not happened, withdrawal from the sources of meaning that would rebuild a life, and a self-directed accusation — that she was not there — that has never been spoken aloud.

IPT formulation

Problem area: grief (complicated bereavement). Symptoms began with the death and mourning has not completed. The treatment aim is to facilitate the mourning that has been avoided — including the ambivalent and negative feelings, which are usually the ones blocked — and then to rebuild interests and relationships.

The ambivalence is present and unspoken. Her mother was, in one sentence Rosa retracts immediately, "not always easy". The idealisation is protective and will need to be approached gently.