The “Therapeutic Lifer”

The concept of the “therapeutic lifer” has by now been well developed in the descriptions of the patients and their courses in therapy throughout this book. It has been counterposed, usually implicitly, but at times more explicitly, against the more usual model of psychiatric illness (at least with the usual outpatient, neurotic-range patients). In this model, illness is taken to represent a dysfunctional state that should be properly responsive to a single appropriately planned treatment course, which, whatever its open-endedness, and whatever its overall length, does have some natural termination point. In somatic illness, there has of course always been another model as well—that of chronic illness. At times, such ilness is normally progressive (e.g., severe rheumatoid arthritis or osteoarthritis), and the therapeutic role is to ameliorate, as best as possible and for as long as possible, the advancing pain and disability. In other such illnesses (e.g., diabetes, pernicious anemia), there can be substantial hope, at least from certain perspectives, of staying any disease progression and working to ensure as close as possible a normal (symptom-free and complication-free) life course. With still others (e.g., various kinds of cardiac impairment), the prognosis in relation to the possibilities for effectively stabilizing the individuals' functioning may be intermediate. What all these afflictions share in common, however, is that they are chronic, and that good functional maintenance, rather than true illness cure, is the reasonable treatment goal. And a corollary to this, of course, is the concept of continued maintenance care by the treating physician that is regular and lifelong, however the actual visits to the physician are eventually spaced.

With the advent of the psychoactive medications, and the almost simultaneous spread of the community mental health center movement and its implementation by federal law and commitment,