Attachment avoidance may appear as self-sufficiency, emotional distance, minimisation of need, or disengagement under relational stress.
Look for
Minimises distress
Patient language
“I do not need anyone”
Formulation use
Attachment avoidance may explain disengagement just when support, closeness, or dependency becomes clinically relevant.
Avoidance reduces distress in the short term but commonly maintains anxiety, trauma responses, functional impairment, and interpersonal narrowing.
Look for
Missed appointments
Patient language
“I just avoid it”
Formulation use
Avoidance may explain why distress persists despite the patient working hard to stay safe.
Shame often links trauma, attachment threat, avoidance, concealment, anger, self-criticism, and disengagement from care.
Look for
Downcast gaze
Patient language
“There is something wrong with me”
Formulation use
Shame may explain avoidance, anger, withdrawal, or self-attack when the patient feels exposed or dependent.
Emotional dysregulation is a transdiagnostic formulation mechanism that can amplify impulsivity, interpersonal rupture, avoidance, and risk.
Look for
Rapid affect shifts
Patient language
“It goes from zero to one hundred”
Formulation use
Emotional dysregulation can explain why stress rapidly becomes behavioural, interpersonal, or risk-relevant.
Negative core beliefs bias attention and meaning-making, often linking early experience to current automatic thoughts, affect, and behaviour.
Look for
Global self-statements
Patient language
“I am not good enough”
Formulation use
Negative core beliefs provide a bridge between developmental learning and current interpretations.
Perfectionism can drive achievement but may maintain anxiety, depression, shame, procrastination, avoidance, and burnout.
Look for
All-or-nothing standards
Patient language
“If it is not perfect, it is a failure”
Formulation use
Perfectionism may organise coping around preventing shame, criticism, or loss of worth.
Reassurance seeking can soothe briefly but may maintain uncertainty intolerance, anxiety, dependency cycles, and interpersonal strain.
Look for
Repeated checking questions
Patient language
“Are you sure?”
Formulation use
Reassurance seeking may show how anxiety is regulated interpersonally while uncertainty tolerance remains low.
Splitting can simplify unbearable ambivalence but may destabilise relationships, teams, and self-experience.
Look for
Sudden idealisation or devaluation
Patient language
“They are the only one who understands me”
Formulation use
Splitting can organise otherwise overwhelming mixed feelings, but it may make alliance ruptures more likely.