1. The patient believes therapy is a passive or magical process. As part of the clinical picture, some Axis II patients see both problems and solutions as external to themselves. They may appear to be highly motivated, but their motivation is to simply absorb some curative effect from being around the therapist. Some believe that it is the therapist’s job to do all the work, with little or no input from them, and they hope to gain both insight and behavioral change from the remarkable observations and directions that the therapist will provide. They may idealize or flatter the therapist initially but easily become defensive or disenchanted with the expectations of productive therapy.

Clinical Example: Carolyn, a 40-year-old housewife with no children, entered therapy to “figure herself out” after a friend recommended cognitive ther- apy as a productive alternative to psychoanalysis. She had a history of recurrent depression and a personality disorder combining narcissistic and dependent features. After thorough explanation of the parameters of cognitive therapy and the importance of patient involvement, Carolyn remained vague about pinpointing any problems or goals, telling the therapist, “I expect you to figure that out.” The homework of planning one or two items for the session agenda was explicitly assigned several times, and each time Carolyn returned for the following ses- sion without anything for the agenda but a pleasantly stated redirection of the session agenda to the therapist. When gently prompted for greater participation in the session structure, Carolyn became defensive and scolded the therapist for not meeting her expectations for advice and instructions.

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.