Know who is actually driving a treatment, because the agent is not always the patient, and even one patient has a part that wants change and a part that does not. Good treatment sorts what the patient can't do from what they won't, and leaves them more responsible for their choices, not less.
Who drives the treatment
Treatment has multiple agents, and the agent is not always the patient. It can be the state, for safety or for someone who lacks insight, or a parent on behalf of a child.
“there are multiple agents that drive a treatment. And the agent can be the state for purposes of safety or for the purposes of giving treatment to somebody who lacks insight. The agent can be a parent on behalf of a child, which you see in child psychiatry”
5:14Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025 Be clear in your mind who all the agents of treatment are and whether they should be. If not, attention splits among them and forging an alliance with the patient becomes extremely hard.
“You need to have clear in your mind who are all the agents of treatment and whether or not they should be agents of the treatment. Because if you don't, The attention field gets split up between the various agents, and that makes it extremely hard to forge a therapeutic alliance with the patient”
6:54Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025 Even one patient is not one agent. Part of them wants to get better and change; part wants to stay the same, feel safe and avoid new and scary things. Ally yourself with the part that wants to change.
“there's a part of the patient that wants to get better and change. There's a part of the patient that wants to stay the same. feel safe or at least avoid new and scary things. And so you have to ally yourself with the part of the patient that does want to change against a part that doesn't”
9:24Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025
Responsibility
Every treatment has to settle what the patient can't do versus what the patient won't do, whether or not you put it in those terms.
“what is it that the patient can't do versus what is it that the patient won't do? And even if we don't think of it in these terms, ultimately we have to, you know, as the clinician, we have to come to some determination about this”
42:37Understanding Borderline Personality Disorder with Dr. Mark L. RuffaloDec 2024Guest episode Good therapy leaves the patient feeling more responsible for their choices, freer in the world and more self-responsible. Therapies that move them the opposite way are potentially quite dangerous and harmful.
“good therapy ultimately is, leads to the patient feeling more responsible for their choices in life, a greater degree of freedom in the world, a greater sense of self-responsibility. And I think therapies that sort of move the patient, if you will, in the opposite direction are potentially quite dangerous and quite harmful”
44:51Understanding Borderline Personality Disorder with Dr. Mark L. RuffaloDec 2024Guest episode A useful mantra: it's not your fault, but it's your responsibility.
“That's what everyone will always say in response to that. So I'll use one of my mantras. It's not your fault, but it's your responsibility. That's how I feel”
4:47Tips to Avoid Burnout in Psychiatry (Outpatient, mostly)Mar 2026
Involuntary settings
When a patient says you are keeping them hospitalized, it helps to understand that the law is: a system of rules society has agreed on, for good reasons.
“it helps to understand that the law is keeping them hospitalized, the law in society. Right. There is just a system of rules that we've vaguely agreed upon as a system to execute for good reasons”
8:16Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025 Name your role plainly: if you do not do your due diligence, you could lose your license and they could be in danger. Then ask for their help: you are not perfect, so help me out here.
“if I don't do my due diligence under the general rules and how people do this job, I could lose my license and you could be in a lot of dangers and I don't know what's going to happen. You know, I'm not perfect. So help me out here”
52:53Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025
Talking to patients
When asked whether it is their fault, say it surely was not their fault that they developed the condition. Their biology and what they experienced in life contributed.
“it surely was not your fault that you developed this condition. Now, there may be certain things about your biology that contributed. And most certainly there were certain things about what you experienced in life that contributed to developing this condition”
37:23Understanding Borderline Personality Disorder with Dr. Mark L. RuffaloDec 2024Guest episode
From these episodes
- Tips to Avoid Burnout in Psychiatry (Outpatient, mostly)Mar 2026 · 1 point
- Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025 · 5 points
- Understanding Borderline Personality Disorder with Dr. Mark L. RuffaloDec 2024 · 3 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.