okay... this is going to be hard... i can't quote the whole damned book ;-)

'Kohut asserts that defence-resistences perform specific self-preserving functions, and that strong resistences are mainly motivated by shame. In this process the therapist needs to be sensitive to the hidden expressions of the defences against and the experience of this nonverbal affect. These become especially prominent at points of 'intersubjective disjunctions'. Are there any preconditions in the therapy that increase the probability of such disjunctions? As a result of the empathic process of the initial phase of treatment, the patient develops a positive anticipation of a continuing self-sustaining relationship with the therapist, and on the basis of this expectation of mirroring he or she engages in an open self-display of his or her affective inner world. The therapist's failure to do as expected is experienced as a non-confirmation that triggers shame. In a previous chapter I suggested a developmental model that serves as a prototype of all shame experiences. The individual, in a high energy state of excitement and elation, exhibits itself to a menaingful object. Despite an expectation of an attuned mutual amplification of positive effect, the self suddenly experiences a misattunement, triggering a shock-induced psychobiological state transition and a deflation of narcissistic affect. The object-inducing energy depletion causes an impairment of self-cohesion and it phenemenologically experienced as a discontinuity.

Thus, the immediate, proximal internal event of any shame experience is activated internal fantasy of a symbiotic attunement, of a motivation to move psychologically closer to the therapist who has become an emotionally significant object, but the external reality does not match that need and so the patient rapidly and reflexively withdraws from view of the therapist. Clinically this means attending to the patients 'non verbal expressions of the self' such as turning the face away, gaze aversion, covering the face with the hands, or blushing... Postural changes are seen in slumping or seeming to shrink, as if hiding. It is also important to recognise the *language* of shame; rarely is the specific word used, and when it is it usually denotes a critical moment in the psychotherapy session. More commonly the patient will speak of feeling foolish, ridiculous, pathetic, insignificant, worthless, etc and will talk about feeling exposed or wishing to make himself invisible...

The patient who constantly defends against experiencing and exhibiting conscious shame in the presence of an emotionally meaningful other must at some points experience it in the transferential relationship with the therapist. As mentioned, these moments are critical events in the ongoing interpersonal process of psychotherapy as they are associated with breaks in the positive transference. In the same way as the bond between the infant-mother dyad was tested... The therapeutic relationship is 'stress-tested' at exposed moments of the painful emergence of shame into consciousness thereby vulnerably revealing the affect regulatory deficit...

Patients can tolerate increasing amounts of conscious shame (narcissistic pain) under the aegis of the therapist who can serve as an external regulator of this painful affect. The therapist, in the same way as the attuned practicing mother, mediates affect regulatory selfobject functions for the patient, especially in disjunctive state transitions. This is specifically accomplished by the therapists repeated demonstrated ability to consciously, and especially unconsciously, affectively resonate ith the patient allowing him or herself to stay emotionally connected with and available to the patient during the oscillating seperation and reunion periods of the dynamic transference that occur over the course of the theraputic relationship. In order to do this the therapist must be able to tolerate the painful affect in him or herself. This requires that the clinician must recognise and deal authentically with the intersubjective shaming that occurs in the therapeutic session. The 'recognition and acceptance of the patients shame lies at the heart of empathetic listening in the analytic process'. This process is extremely important during periods of stress which propel the patient into dysregulated affect - intense, spiralling shame states which are beyond the range of active coping and therefore beyond his capacity to resolve by himself. At this point of failure of narcissistic defences against shame, narcissistic pain breaks through into consciousness. Much to his shame, the patients intense attachment need is, at the same moment, reflected to himself and exposed to the significant other. Consequently, he feels the intense anxiety of needing another, of being forced into reunion, and experiences this need as a narcissistic injury.

http://www.amazon.com/Affect-Regulat.../dp/0805834591