The article examines the role of psychodynamic formulation in directing clinical rehabilitation following acquired brain injury, focusing on the contribution of Heintz Kohut’s theory of self-psychology. This is based on a case study of a man showing poor emotional and functional recovery following mild traumatic brain injury. Self psychology formulation was used to understand psychopathology and guide psychodynamic therapy. Brain injury served as a severe narcissistic injury, which threatened self-worth and triggered tremendous distress. However, this man was particularly vulnerable as due to a relational trauma as an infant he was deprived of socio-emotional learning during critical periods of right brain development. This postulates how detrimental early socioaffective experiences provided a growth inhibiting environment for his developing brain. Consequentially it is likely that he had impaired maturation of right brain which impacted on his ability to achieve a coherent self. Thus his poor recovery may be the outcome of two consecutive brain injuries: one developmental due to relational trauma and the other acquired as adult due to right frontal traumatic brain injury. This helps provide a satisfactory formulation as to why a mild brain injury can result in devastating functional and emotional outcome. Therapeutic work focused on constructing a sense of coherent self as a means to correct for unsatisfactory selfobject experiences in early life and current family dynamics. It is hoped that the article contributes to the growing understanding of the central role childhood experiences can play in shaping the adult’s reactions to a traumatic brain injury as well as the complex relationship with pre-injury personality, injury severity and functional outcome.