What is an Identified Patient?

Introduction

Identified patient (IP) is a clinical term often heard in family therapy discussion.

It describes one family member in a dysfunctional family who expresses the family’s authentic inner conflicts. Usually, the “designated patient” expresses their physical symptoms unconsciously, unaware they are making overt dysfunctional family dynamics that have been covert and which no one can talk about at home. Occasionally, the identified patient is partly conscious of why and how they have become the focus of concern in the family system.

As a family systems dynamic, the overt symptoms of identified patient draw attention away from the “elephants in the living room no one can talk about” which need to be discussed, such as a pending separation or divorce. If covert abuse occurs between family members, the overt symptoms can draw attention away from the perpetrator(s).

The identified patient is a kind of diversion and a kind of scapegoat. Often a child, this is “the split-off false carrier of a breakdown in the entire family system,” which may be a transgenerational disturbance or trauma.

In Organisational Management

The term is also used in analysing dysfunction in businesses where an individual becomes the carrier of a group problem.

Origins and Characteristics

The term emerged from the work of the Bateson Project on family homeostasis, as a way of identifying a largely unconscious pattern of behaviour whereby an excess of painful feelings in a family lead to one member being identified as the cause of all the difficulties – a scapegoating of the IP.

The IP – also called the “symptom-bearer” or “presenting problem” – may display unexplainable emotional or physical symptoms, and is often the first person to seek help, perhaps at the request of the family. However, while family members will typically express concern over the IP’s problems, they may instinctively react to any improvement on the IP’s part by attempting to reinstate the status quo.

Virginia Satir the wellspring of family systems theory, who knew Bateson, viewed the identified patient as a way of both concealing and revealing a family’s secret agendas. Conjoint family therapy stressed accordingly the importance in group therapy of bringing not only the identified patient but the extended family in which their problems arose into the therapy – with the ultimate goal of relieving the IP of the broader family feelings he or she has been carrying. In such circumstances, not only the IP but their siblings as well may end up feeling the benefits.

R.D. Laing saw the IP as a function of the family nexus: “the person who gets diagnosed is part of a wider network of extremely disturbed and disturbing patterns of communication.” Later formulations suggest that the patient may be an “emissary” of sorts from the family to the wider world, in an implicit familial call for help, as with the reading of juvenile delinquency as a coded cry for help by a child on his parents’ behalf. There may then be an element of altruism in the IP’s behaviour – ‘playing’ sick to prevent worse things happening in the family, such as a total family breakdown.

Examples

  • In a family where the parents need to assert themselves as powerful figures and caretakers, often due to their own insecurities, they may designate one or more of their children as being inadequate, unconsciously assigning to the child the role of someone who cannot cope by themselves. For example, the child may exhibit some irrational problem requiring the constant care and attention of the parents.
  • In Dibs, an account of a child therapy, Virginia Axline considered that perhaps the parents, “quite unconsciously…chose to see Dibs as a mental defective rather than as an intensified personification of their own emotional and social inadequacy”.
  • Gregory Bateson considered sometimes “the identified patient sacrifices himself to maintain the sacred illusion that what the parent says makes sense”, and that “the identified patient exhibits behaviour which is almost a caricature of that loss of identity which is characteristic of all the family members.”

Criticism

Extending the original concept of the identified patient, the anti-psychiatry movement went on to argue it is the family who is chiefly mad, rather than the individual the family identifies as ‘sick’ – positing also that the latter might in fact be the least disturbed member of the family nexus.

Literary and Biographical

  • In the play The Family Reunion, T.S. Eliot writes of the protagonist: “It is possible You are the consciousness of your unhappy family, Its bird sent flying through the purgatorial flame”.
  • Carl Jung, who viewed individual neurosis as often deriving from whole family or social groups, considered himself a case in point: “I feel very strongly I am under the influence of things or questions left incomplete and unanswered by my parents and grandparents and more distant ancestors…an impersonal karma within a family, which is passed on from parents to children”.

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