Every patient is either easy to treat or difficult to treat, depending on the clinician's perspective. This perspective is the result of the clinician's formulation of the case and the negotiated goals of the treatment. In recent years, psychiatric treatments, pharmacologic and otherwise, have so proliferated that therapeutic impasse may be regarded simply as an opportunity to try the next treatment. Stepping back to reevaluate, reformulate, and renegotiate is less common than it once was. It is difficult to resist the temptation to try a different medication, add a booster, replace this psychotherapy with that one, and so on until finally, perhaps as a result of exhaustion on the part of the clinician, the patient is labeled "treatment refractory."