The Myth of the ‘Identified Patient’

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By UB staff therapist Michael Maloney, LCPC

The Identified Patient.  What does that mean? To quote Wikipedia the Identified Patient is “a term used in a clinical setting to describe the person in a dysfunctional family who has been unconsciously selected to act out the family’s inner conflicts as a diversion.”  The term helps explain a pattern that occurs with family systems where all the issues that arise are about the one person or the Identified Patient.

The Identified Patient might play out in a couple of ways:

  • The Identified Patient in the family has been recently diagnosed with a mental illness or a medical condition
  • The Identified Patient has a history of trauma or PTSD
  • The Identified Patient shuts down or blows up during conflict
  • The Identified Patient isn’t doing well in school, work, socially, etc.  
  • The Identified Patient is between jobs

The story of the Identified Patient is a myth that if that person would just fix their issues then all the problems would just disappear.  It is often that those are issues that do need to be addressed. But is that the full story?

Finding Road Blocks to Needs and Finding Alternative Pathways

Tom feels overwhelmed when he get in conflict with his wife Karen.  He has shared with her that it might be a symptom of his depression.  Karen then feels that she can’t approach Tom is issues and concerns she has or else Tom will shut down.  She may start to feel resentful of Tom and his depression and tells him to work on it. If the couples does get in a  fight it usually leads with Karen yelling that Tom needs to find a therapist to work on his depression.

Karen might be feeling resentful because her needs don’t get to be addressed.  She might feel angry if the depression gets Tom out of a difficult conversation that she needs to have.   Karen might be feeling powerless in managing Tom’s depression and shutting down. All these experiences are Karen’s that get put out of the conversation if the focus is just on Tom as the Identified Patient.  Karen has needs too.

Karen needed to feel that she was allowed to bring up her concerns.  The depression became a barrier to conversations. What might have helped Karen is if she knew how to connect with Tom when he was overwhelmed and/or depressed.  Tom did need to work on his depression, but the couple (not just Tom or Karen) also needed to work on how they communicated. Maybe he could work on asking for Time Outs and restart the conversation.  Maybe he could listen to Karen, but ask for more time to respond to her concerns. Maybe they could share an emotional journal. If a roadblock to conversation (or whatever need is there), then it should not be the end of trying to find a way.

Vulnerability

Janet and Esme are in couples therapy to work with dealing with Janet’s PTSD and how it impacts the relationship.  However Janet feels like she does most of the talking and all the issues are around her. This brings a sense of shame that if she could manage her trauma and symptoms better there would be no issues in the relationship.  Later Esme reveals that she struggles with feeling powerless and useless in supporting her partner trough her trauma. Emse reveals how worried she feels for Janet and is working with her therapist in managing her feelings of worry and self care while she finds ways to support Janet.  

This is helpful for Janet, as she can hear that A) Esme is also working on things and thus feels less alone and B) that she can support Emse as Esme supports her.  Janet feels like she can share and ask for support if Esme is also able to ask for support too.

Often we ask the Identified Patient to be vulnerable.  To share their process and their trails. The other parties are worried and are anxious that the issues aren’t being addressed.  However vulnerability is something that needs to be earned. The term Vulnerable means to leave oneself exposed to harm. If we put all our emotional insecurities out on the table, we leave them vulnerable to be judged.  But in the case of Janet and Esme, when Esme was able to share her worries and concerns (her vulnerabilities) then Janet felt more at ease in sharing hers. All of a sudden giving her partner updates on her treatment became part of taking care of her partner and not am seeing if her treatment progress was meeting Esme’s expectations.  Vulnerability requires vulnerability shared. This creates more safety to allow oneself to feel exposed.

The Identified Patient and The Burdens to Carry

Kevin is between jobs and feels a huge amount of pressure to find a new one as his parents and wife, Len,  are anxious. Kevin is finding that the job search process exhausting both mentally and emotionally. When he brings this up to Len gets angry and she yells that her day was REALLY hard as she had a lot of stress at work and is feeling the burden of being the sole breadwinner of the family.  Kevin then feels he can’t bring up his day since it will only make Len angry and she is taking on a bigger burden.

However when Kevin tries to use some of his self care activities like hanging with friends, reading, exercise, or playing video games, Len also get angry at him. Kevin then starts to feel frustrated at Len and voices this to his parents.  His mom then tells him that he needs to find a job and not waste his time goofing off. His mom then voices she worries if they are able to support themselves with him not having a job. Kevin’s relationship with his wife and parents begins to deteriorate.  He has learned that going to them with his concerns or needs will only lead to him being scolded. Kevin is also finding it harder to stay motivated to look for jobs and starts playing video games more and more to reduce his anxiety about the job search.

Kevin is taking on a lot of the blame and anxiety of the system he is in.  Everyone is anxious about him finding a job: himself, Len, and his mom. The pressure to fix things (i.e., find a job) becomes more of a burden because now it becomes releasing more of the anxieties and feelings of self worth from others.  This feeling of pressure creates dread in doing the activity and dread decreased motivation. Kevin might have thoughts about feeling incompetent in finding a job or having to carry the weight of the anxiety of multiple people. But he now doesn’t know how to address it because he is stuck in the role as the the Identified Patient.  The myth states the only way out is to find a job. However the burdens of being the Identified Patient makes it a Herculean effort to complete. Kevin might need support and self care to complete this task (which is still part of his goals) but he doesn’t feel he is allowed to ask anymore.

Len and Kevin’s mom also need support, but they need to learn that their anxieties and insecurities are their responsibilities.  It would help Kevin if they could share their concerns without putting on more pressure on Kevin. Kevin needs to work on boundaries to figure out what is his burden to carry and not take on all the anxiety.   

When the focus is on one person creating problems for an entire system, be it couples, family, friendships, or work, it can create problems where people feel stuck.  In all the examples above so many people felt powerless in change. Each person is responsible for their own needs and needs to feel okay asking for support without placing all the burdens on the other.  Esme and Janet were both seeing their own individual therapists to work on their own issues, so when it was addressed in couples therapy they could clearly support each other. Make sure you are receiving the support that you need to keep you relationship system going.  Therapy, both couples and individual, can help build the practices you need to break out of these myths that we create and the feelings of being stuck.