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Many years ago, I heard Dr. David Rosenfeld discuss a case of a senior analyst. As the analyst presented her process notes, she noted that the patient's voice became softer and softer as the session progressed. The analyst kept asking the patient to repeat herself. At this point in the presentation, Rosenfeld whispered to the presenter, “The patient wants you closer.” The presenter replies, “What? I am sorry. I didn't hear you.” Rosenfeld replies, “Exactly! You need to be closer to the patient. The patient needs to pull you close like a baby with a mother, this is what the patient is telling you.” This intimate exchange has stayed with me over the years. The tenderness of Rosenfeld's intervention was startling. He was conveying something so simple and yet so complex, reminding us that the patient is communicating something very important about her internal state, her transferences, and it is our job to understand as best as we can.
Rosenfeld has written many articles and given many presentations on issues of autistic and psychotic states, including his books translated into English: The Creation of the Self and Language: Primitive Sensory Relations of the Child with the Outside World ; The Soul, the Mind, and the Psychoanalyst ; and The Psychotic: Aspects of the Personality . Central to his writings is an exploration of aspects of autistic and psychotic states that can be difficult for clinicians to understand or respond to in a useful therapeutic way. He often reminds us that the patient cannot always communicate inner pain just with words. Rather we must learn to pay attention to the earliest communication that may reverberate in the patient's symptoms and delusions. He recommends tracking the unconscious communication through our countertransference and how we feel in the room with the patient (as in the example above). In particular, he suggests that we pay attention to what is inside and what is outside and follow the way that the