"Difficult patients" may be hard to define, but they are well known in many clinical settings. Although they need and demand help, many ultimately reject it when it is provided. These individuals are identifiable by a combination of diagnostic and functional criteria and their disproportionate impact on the mental health system. In this drama there is a problem of interactive fit: a negotiation between clinician and patient to reach consensus about treatment goals and role performance. The discrepancy between intact functioning and unpredictable maladaptive behaviors leaves caregivers confused, disappointed, and angry. In this issue, the article by Bauke Koekkoek, R.N., C.N.S., and colleagues provides an overview of what is known about difficult patients in mental health care. A focus on patients' behavior can lead to ignoring the impact of the diverse set of values and expectations that clinicians bring to the interaction, which are affected by our theoretical formulation of mental illness, our therapeutic roles, and the treatment settings in which we practice.