Patients with treatment resistant disorders pose a major problem to clinicians of all theoretical perspectives, including psychodynamic therapists. Treatment of such patients often results in stalemates and impasses, and acting out is a frequent phenomenon. This paper addresses the value in work with such patients of looking beyond the concept of acting out, which is a one-person definition of a problem, toward the concept of enactment, which recognizes the roles both therapist and patient play in the phenomenon of treatment resistance.