This article examines the dynamics of the casework relationship from a holistic perspective. The significance of the interplay between caseworker and client often evades efforts at objective evaluation. Too often emphasis is placed on concrete indications of progress. Staff who look solely at these measures may become frustrated and lose sight of internal change not easily revealed in empirical studies. This article looks at how long-term casework relationships revolve around existential issues that lie at the heart of psychiatric rehabilitation. These relationships, however resistant to stringent measurement, enjoy value apart from specific achievements and merit recognition in their own right. The ordeal of change that both parties endure leaves them heir to a legacy of struggle and renewal.

Despite growing research on the treatment of severe mental illness, little attention is devoted to the internal experience of therapists who strain to ward off disillusionment and despair as they try to hold out hope and reconfigure expectations over a course of therapy that may extend many years. The first-person literature of recovery points repeatedly to the importance of maintaining faith in the face of resignation, yet much less appears in the professional literature about the struggles of therapists who live with apprehensions about the meaning of their work. The relative disappearance of commentary about this phenomenon, a legacy of the biological revolution in psychiatry, shields practitioners from self-examination and prevents a more penetrating look at the inner workings of psychotherapy in the treatment of long-term mental illness.

A special member‐staff relationship is necessary for psychiatric rehabilitation to be effective.

The sweeping revisions in the understanding of major mental illness brought about by the biological revolution in psychiatry moved the spotlight away from the treatment relationship. In recent years, however, a resurgence of interest in subjectivity underscored the fact that despite dramatic scientific breakthroughs the existential realities of illness were largely unaltered. Even with this shift in inquiry, however, little attention was shown to the inner experience of practitioners engaged in long-term therapeutic relationships where movement of any kind was barely detectable. Clinicians and clients alike frequently travel a long and difficult road in search of pathways to recovery. Tracing their shared journey through a detailed case presentation illuminates the interior worlds of both travelers and illustrates that neither is left untouched by the complexities of change.

After the waves of change resulting from the biological revolution in psychiatry gradually receded, interpersonal approaches to the study of serious mental illness, long in decline, once again regained currency. The renewed emphasis on subjectivity, spurred in large measure by the burgeoning recovery movement, brought the lived experience of illness to the forefront of research. However, inquiries into psychotherapy paid little heed to the interior world of therapists immersed in the longterm treatment of severe mental illness. Their experiences failed to garner much attention despite the adoption of intersubjective perspectives in broader interpretations of psychotherapy. The purpose of this essay is to look anew at the dynamics that arise in the psychotherapy of major mental illness and recast light on the struggles of both clients and clinicians through an intensive case presentation exploring the contours of identity.