Short case example
A patient misses therapy after disclosing trauma because they feel exposed and “disgusting,” then interprets the absence as proof they are failing.
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Formulation mechanism
A painful self-conscious affect in which the self is experienced as exposed, defective, unacceptable, or at risk of rejection.
What matters now
Fit, function, and alternatives
Use sequence, function, patient language, and disconfirming evidence to decide whether this hypothesis adds explanatory value.
Across the formulation
Short case example
A patient misses therapy after disclosing trauma because they feel exposed and “disgusting,” then interprets the absence as proof they are failing.
Formulation language
Shame appears to organise the patient around hiding and self-protection, reducing exposure but maintaining isolation and self-criticism.
Treatment implications
Name shame gently, separate protection from self-attack, and build tolerable disclosure or repair steps.