The “Identified Patient”

Over and over again I see it written: the scapegoat is troubled, the problem child, the troublemaker, even the household rebel. Psychologists and other writers, from the well-known like John Bradshaw to the most obscure blogger, publish works that make it look like the scapegoat, because of his or her behaviour, might actually deserve both the role and the disdain forced upon him.

My own experience does not bear this out. M. Scott Peck, in his book “People of the Lie,” references the “identified patient.” According to Wikipedia, “Identified patient, or ‘IP,’ is a term used in a clinical setting to describe the person in a dysfunctional family who has been subconsciously selected to act out the family’s inner conflicts as a diversion; who is the split-off carrier of the (perhaps transgenerational) family disturbance. The term emerged from the work of the Bateson Project on family homeostasis, as a way of identifying a largely unconscious pattern of behavior 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 identified patient - 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 identified patient’s part by attempting to reinstate the status quo.”

That last paragraph strikes a responsive chord in me. I was not only the first person to seek help in my family, I was the only one. NM’s one foray into psychology for me during my childhood—part of a custody battle with my father in which she wanted a psychologist to testify on her behalf—was abruptly cancelled when the therapist was more interested in talking about her than about me. I don’t remember this at all (part of that blank period in my childhood for which I have virtually no memories), but I clearly remember NM citing this as an example of the uselessness of psychology/psychiatry: she took me to a therapist because I was obviously disturbed (I wanted to live with my father, not her) and the therapist was focussing on her instead of me. NM, who had an agenda that had nothing to do with my emotional well-being, took me to that psychologist as the “identified patient” (a person who is taken to therapy by his or her family, as being a problem or having problems), but the therapist saw right through her. We never went back for a second session.

Peck says this child, the identified patient, is the family member who is identified as the source of the family difficulties. And while some of these children are, in fact, acting out, it is usually a problem in family dynamics that is the true source of problem, and if the child is acting out, it is in response to those dynamics. In other words, the child doesn’t really have to be a problem to be designated the scapegoat, although some children become a problem as a result of their being cast into the scapegoat role. Then, they are blamed not only for their acting out behaviours, but for the problems of the entire family system as well.

I read “People of the Lie” long before I had any notion of narcissism and personality disorders. But I was struck with the similarity between the “identified patients” and my self-identification as a scapegoat. I had come across the term in my reading and it immediately resonated within me: my brother, who was always in trouble at school, at home, even in the neighbourhood, was seldom punished for his misdeeds and his lies…often mind-bogglingly transparent…were always accepted as truth. For me, I was blamed and punished for not only my mistakes (which were interpreted as deliberate defiance) but for his misdeeds—his misbehaviour was my fault because I “allowed” him, I didn’t stop him, I was the oldest and he was my responsibility. This is classic scapegoating and, since I was already being blamed for ruining NM’s life by my very existence, it wasn’t much of a leap to lay everything wrong the family at my feet.

In “People of the Lie” Peck describes the parents of a little boy so deeply depressed he was hospitalized. That year for Christmas they had given the boy a .22 rifle, the exact same rifle his older brother had used to commit suicide. When confronted by Peck and the message their “gift” conveyed…that they wanted him to commit suicide, too…the parents became immediately defensive, dug their heels into denial, and refused to entertain the thought. They became angry at Peck, insisting their son was the sick person, not they. Peck defines evil as “militant ignorance” and the behaviour of these people, angrily defensive and unwilling to accept the truth of their actions and the message those actions conveyed to their grieving younger son, exemplify not only their ignorance but their militant defence of it. To remain blameless, to be able to see themselves as good people and good parents, they sacrificed their son, making him the sick one, the identified patient, the one with the problems, and completely absolved themselves of any responsibility for his depression. No, he was the sick one and the doctor needed to focus on him, not on them. They reacted to Peck’s rejection of their son as the “identified patient” in much the same way my NM reacted to that psychologist rejecting me as the same.

This is not to say that the identified patient is not suffering, does not need some kind of therapeutic intervention. Most likely s/he does. But critical is the understanding that the reasons the IP needs help is not because s/he is the centre of the family dysfunction. Often the child singled out as the scapegoat is the most emotionally healthy, most cognitively aware, most fundamentally balanced member of the household. The child may act out to draw attention to the family in a subconscious hope of getting help…or the child may be so successfully subdued that s/he simply goes along, not making waves, either biding her time until she can escape or becoming so imbued with the family mythology that she buys into it and accepts that she is at fault, even though she cannot figure out how. The identified patient has been damaged by the dysfunctional family system, but she is not the only damaged person and she is not the cause of the dysfunction.

Is it possible to have a dysfunctional person inside a functional family? I believe it is, using my NM and her FOO as an example, but I think it is rare. Perfectly normal families can have a family member who is substantially different from the rest of them. We are not blank slates upon which our parents write: if we were, all of us ACoNs would be the same and we are not. We each bring a unique personality and set of traits with us when we come into the world and it may well be that there is something in our particular make up that strikes a negative note in our NMs and causes them to single us out as the scapegoat.

Identified patient is a psychological term that, in my mind, equates to scapegoat. “A dysfunctional family needs someone to focus on, someoneto blame things on, someone to point to when things go wrong… It means that in a sick family system, the group has subconsciously elected one person to act out all the family sickness in a very overt way while the rest of the family acts it out in a covert way. Even if the IP tries to act “not sick,” the family will send messages to “get back where you belong” and set the IP up for failure.” How much does this sound like the family dynamics surrounding the scapegoat?

“It’s not that the identified patient is any sicker than the rest of the family, in fact they probably aren’t, but they are the one through whom the family channels all of its “stuff.” The family dynamic is to keep things status quo, to keep its eyes trained on the IP.” Have you tried going NC—or even LC—only to find members of your family going out of their way to suck you back into the drama? That isn’t because they love you and miss you (as they may well say) but because they need you to be there to take the blame, to be the negative focus, to be the disappointing one against whom they can all compare themselves and come away superior.

Some of us disappear from the family scene and we don’t get hoovered. This is the function of the “ignoring types,” the family dynamic that treats you like you are invisible until something is needed from you. In such situations “…the identified patient, or IP, is viewed as a troubled individual or, in extreme cases, as someone with whom the family would be better offwithout.”You are still the IP or scapegoat, but in this case, the family had decided that your absence makes them whole as they can continue to find ways to blame you even at a distance.

“Usually the one who gets help first in the family is the IP. They get out of the family and find out what is wrong because they are tired of being blamed for everything and everyone. Usually their acting out is a normal response to an abnormal situation and they want help.” Some of us seek therapy, others of us seek self-help through books, websites, on-line groups, journaling. Some of us don’t seek help at all and just escape the FOO but continue to replicate our dysfunctional emotional relationships with others, seeking to “get it right” this time…the next time. And some of us just get out and withdraw, licking our wounds and living in a cocoon of hurt.

But we all want that hurting to stop. “…part of recovery is identifying who you were in the family and how you have carried that role into adulthood. See how your role in the family plays itself out in your current relationship and ask yourself if it’s time for a change.

“Being the IP or the one that doesn’t belong can be a [hidden] blessing. If you’ve never belonged, it’s easy to take a step in another direction. Take refuge in exile. It can be a good thing.

“If you’ve been the IP, realize you’re never going to win their approval, so stop trying. You have a role to fill and they’re not going to be happy if you’re not filling it. If you’ve brought it into your relationships, chances are you will not be validated and acknowledged in those adult relationships either.

“Stop seeking approval from people who don’t have it to give. Throw off those old messages…get rid of the negative messages from the family…get rid of “get back where you belong” everytime you try to save yourself.”

Yes, you might fail. You might even fail repeatedly in your efforts to get away, to resist being sucked back into the drama by empty promises and your own broken heart. But if you don’t keep resisting you will get absorbed back into the drama and become nothing more than a broken gear in their dysfunctional machine. They aren’t going to change –there is too much in it for them to keep you in your assigned role—and nobody is going to rescue you. To escape and have your own life, a life of fulfilment and devoid of their drama, you have to shrug off the role they have imposed on you. You have to do it yourself. 

You have to be your own hero.