Situation: Patient arrives late; persists with dramatic storytelling; breaks into sobs when therapist redirects to agenda setting.

Emotion: Frustrated / Disappointed / Uncertain / Embarrassed

Automatic thought(s): This patient will never get it! / We are making no progress using cognitive therapy. / I don’t know what to do next. I must be ineffective with this approach.

Rational response: Contempt on my part will not help, so I could avoid such eternalized judgments and be more sympathetic. She is showing more skill in labeling affect, and identifying thoughts. Also, I’m focusing on the importance of making a list when her obvious priority is interpersonal support. I need to respect her values, help her learn to define problems, and not give up. Just because I feel uncertain does not mean I am ineffective, or have committed any shameful action. My discomfort comes from believing all patients must change quickly, and if they don’t, it’s my fault. Does it make sense that an effective therapist “never” feels uncertain? I can brainstorm some options to try next.