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How Does Someone Become a Family's "Identified Patient"?

Part 1: The identified patient is a proverbial scapegoat.

Key points

  • The identified patient is the proverbial “black sheep,” or symptom bearer, of a family system.
  • An identified patient is often identified as the source of a family’s problem instead of its system's flaws.
  • This can develop when an unhealthy family system unconsciously “outsources” its dysfunction onto an individual member.
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Source: Clique Images/Stocksy

In my work as a relational trauma recovery specialist, the individuals I do my best work with see themselves as “Identified Patients," considered to be, or considering themselves to be, the “Other” in their family system.

Identified Patients are often the first people in the room to nod their heads when the term “Black Sheep” is said. You say “Scapegoat,” and they say yes. They know what it is to feel lonely, unsupported, and possibly alone.

Identified Patients can emerge from abusive, dysfunctional, or chaotic family backgrounds where they faced early childhood adversity — and they can come from families that weren’t so outwardly dysfunctional.

What does it mean to be the identified patient in a family system? While the term “Black Sheep” isn’t a clinical term you can find in the DSM or a counseling textbook, Identified Patient is one you’re likely to hear in clinical settings. The term emerged from the work of polymathic thinker Gregory Bateson's 1972 work on family homeostasis, "The Bateson Project." In the field of family therapy, the term describes what we might call the “symptom bearer” of a family system — someone who, because of a variety of variables, expresses the unresolved and unmanaged psychodramas and strong, often dysfunctional emotions of the group. (One interesting idea in family therapy holds that the Identified Patient of the family system can also carry intergenerational symptoms from those who came before them — so it may not just derive from the immediate dysfunction of the nuclear family unit, but also, potentially, the unresolved pains and sufferings of grandparents, great-grandparents, and so on.)

An identified patient is often identified as the problem by family members and is often brought to therapy for their perceived problems. A classic example from the family counseling space is when parents bring an adolescent into therapy with the primary goal of “fixing” that child, when in fact the work that must be done is with the entire family system. Yes, that one child may be outwardly expressing symptoms and signals that appear in more obvious need of attention, but that person may also be expressing the pain and dysfunction of the whole system. Their problems didn’t emerge in a vacuum and won’t be fixed in a vacuum. The identified patient’s “problems” are reflective of unresolved systems problems and they are serving the role of the proverbial canary in the coal mine, warning of larger, problematic issues in the group.

Now you may ask yourself: In a family that would otherwise claim — and in reality, probably does — love and want to support each other, why would someone implicitly or explicitly be identified as or have to take on the role of the identified patient?

Think of it this way: When a family system is psychologically and emotionally healthy, strong, resilient, and robust, problems can arise and be tended to with resolution, responsibility, and resolve. When a system is not healthy enough to tolerate and metabolize the stressors and painful experiences of its individuals, or any iteration of individuals — when the psychological strength and skills to deal with this are absent — the family system unconsciously “outsources” the anxiety, pain, and frustration they are going through. It's like having a really lousy day at work and then coming home and yelling at your partner even though they did nothing wrong: You've "outsourced” your painful feelings onto a person who was not the cause because you couldn’t regulate yourself. You couldn’t tolerate all the hard feelings inside of yourself so you placed it outside of yourself in order to cope. It might feel good for a little while to get that negative energy out of your system, but ultimately it’s not great for your relationship bond with that person.

The same thing can happen with family systems.

When a system can’t cope with what’s going on over time due to unlearned tools, skills, and ways of being, it can unconsciously (and not intentionally) outsource its big, unresolved feelings onto another person in order to “feel better.” When such outsourcing happens regularly, consistently, or chronically, and when there are distinct power differentials involved (parent over child, for example), this outsourcing becomes a bigger, potentially more detrimental issue.

Family systems that can’t tolerate painful realities “take care of themselves” by outsourcing grief and concern to one member of the family. In this way, they think they’ve taken care of themselves, but in reality, it doesn’t actually help the system as a whole get healthier and makes the experience of the person receiving the outsourcing – the Identified Patient – harder.

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