With my great friend and mentor, Michael Franz Basch, I view psychotherapy as "applied developmental theory." At all times, and in every session, I try to remain aware that this patient who appears so adult on the basis of age and occupation may present a symptom that derives from developmental damage or deficits that occurred at any age. When, for instance, someone tells me that s/he is being followed by little green men who are recording everything s/he says, I ask what these aliens intend to do with the data they collect. When my patient answers "they're going to give all of it to my mother," I have a number of choices.
The (apparently paranoid) thought may be blocked by a number of manoeuvers. Medication may be offered to decrease the level of agitation presumably being handled as a delusion. We may begin to talk about other activities of the alien eavesdroppers in order to learn who they might represent in the unconscious life of the patient. It might be interesting to do an EMDR session to see if some part of the delusion shifted.
But at heart, I believe that the most important difference between the lay person and us therapists is that we ask the question "Is there a time in human development during which such a thought might be considered quite normal?" In the sort of case cited (which I have handled on several occasions) it is easy to remember that children first try to lie to their mothers at about age 5-7. Before this period they tend to think that mother can read their mind, and after this period they know that mother figures things out from evidence poorly understood by a child, but not from some form of telepathy. When I ascertain that the patient is involved with some group of cognitions that fit a specific developmental sequence, I set one part of my mind to keep humming with everything I know about that era of child development.
Usually, if my guess is correct, the patient begins to respond with open gratitude as I maintain the sort of empathic attention that fits best the child I spy within the adult. Both the patient and I know quite well that no one is any age all the time, that even the "craziest" of patients have large areas of "sanity," and that neither of us will insult the other by making premature judgements. I am free to shift from my initial developmental characterization of the presenting complaint, just as the patient is free to shift symptoms from time to time.
Yet the principle remains the same. The goals chosen by a patient who is securely locked in the present as an individual who has handled and profited from each and every developmental challenge are very very different from the goals chosen by someone who has been denied empathic parenting during any of several developmental periods. I do not ask patients about their goals until I have come to some conclusion about develomental issues.
I'm reminded about the patient who wanted to be an executive at a large corporation. A fine goal, but inappropriate for someone who had neither the proper schooling nor the proper business experience. Asked what an executive did, he responded that on that leader's desk would be information that would simple fall into his mind, information that would allow him to perform perfectly. Further discussion revealed that this 45 year old man saw life as an unending series of breasts from which he hoped to nurse, and that his developmental age was further back in early childhood than might have appeared from his initial presentation of self. Therapy for this man involved lots of teaching about the adult world so he could get a real job that fit his abilities and proclivities.
I do ask people about their wishes and goals for psychotherapy, but my approach to the acquisition of those goals depends on my assessment of the developmental functions to which I allude herein.