What is “the identified patient”?
Often known as the black sheep or scapegoat, the ‘identified patient’ is the targeted source of a family system’s dysfunction. The identified patient is often labeled during childhood, and this role can cause serious consequences for people later in life.
Therapists often use the term ‘identified patient’ within the context of family therapy. Whether it’s overt or covert, these individuals have a key role in maintaining the family’s homeostasis.
Why Do Families Have Identified Patients?
Not all families have identified patients. However, many toxic or dysfunctional systems have them (even if they don’t recognize it).
Identified patients essentially “simplify” family distress. Instead of each family member recognizing their part in the system, everyone can redirect to one person as “the problem.” They often subscribe to the belief that if that “problem” could just be changed, they would be a happy and healthy family.
Identified patients may exist in families that have:
- Intergenerational patterns of trauma
- Substance use or other forms of addiction
- Unreliable or neglectful caregivers
- Narcissistic caregivers
- Continuous stressors (financial distress, medical issues, relocation, unexpected pregnancies, divorce)
Identified patients, in a sense, must sacrifice themselves to safeguard the family. They act out the family’s pain and eventually internalize themselves as the fall guy when things go wrong.
People aren’t usually born into the role (although some babies can be, particularly if they are born with medical issues or if the pregnancy was unwanted). However, families will often assign them the role when magnifying typical childhood development issues.
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What Are the Signs of Being an Identified Patient?
People often hear the word scapegoat and can easily identify themselves if they fit within that part. They can easily recall stories of being targeted, harassed, or blamed for causing tension within a family. Here are some key signs that you are (or were) an identified patient.
Identified patients often feel isolated within their families. They often report that it seems like “nobody gets them.”
They may have a trait that is significantly different from other family members (i.e., being adopted, having a disability, liking one hobby over another). Or, they simply may feel like others are more connected to one another than they are to them.
To cope with feeling misunderstood, many identified patients look outside their family systems for support. They might lean on friends or extended relatives. Unfortunately, there’s no guarantee that the outside influences are positive, and young children who feel misunderstood are especially vulnerable to unhealthy peer pressure or toxic friendships.
Being Disproportionately Punished
Many identified patients feel like they received harsher punishments than their siblings. They may feel like their parents essentially targeted them- even if their siblings made similar errors.
And so, identified patients often feel resentful towards both their siblings and parents. They might also develop a sense of learned helplessness, meaning they become conditioned to believe their current situation is inescapable.
Being Dragged to Many Specialists
Some parents try to “fix” an identified patient by outsourcing the work to professionals. If this is the case, they may have made you meet with many therapists, doctors, or other healthcare providers.
When the family is heavily invested in maintaining an identified patient, they refuse to examine their own part in the dynamic. Therefore, if a therapist recommended family therapy, they are apt to fire that therapist altogether. Or, if a teacher encourages the parent to be more hands-on or patient with the child, the parent will likely dismiss that teacher’s advice as unhelpful.
Switching to Golden Child Role
Sometimes, identified patients “graduate” out of their role when another person takes their place or when they start achieving significant success.
For example, let’s say there are three children in a family. The middle child has been the identified patient for many years. However, the younger child develops a severe drug addiction, and the parents start diverting all their attention to him.
The middle child does his best to take care of his younger brother. He tries to get him care and attention. He also starts excelling in school (as a way to “escape” from feeling stressed at home).
This middle child may then “rise” to become more of a hero within the family. However, he is still vulnerable to losing his status (and he certainly knows it).
It’s no surprise that many identified patients have low self-esteem. Many of them also lack any real sense of worth or identity. If they’ve been conditioned to believe they are bad, it can be very challenging to change that core perception.
Low self-esteem is a risk factor in numerous mental health conditions, like mood, anxiety, eating, and substance use disorders. Identified patients may start experiencing these mental health problems in childhood or adolescence.
Attachment starts in infancy, but identified patients cannot rely on their caregivers for emotional support. From a young age, they often must fend for themselves. As a result, they may have significant trust issues towards others.
These attachment issues often persist into adolescence and adulthood. Identified patients may either become overly clingy or insecure in their relationships. Or, they may be entirely guarded and disconnected from others.
Identified patients often feel anger towards themselves, their families, and the outside world. Because home feels so unjust, everything else may feel unjust, too.
Young children, of course, may not be able to verbalize this process. Instead, they often act out at home or school. They may exhibit defiance, get into fights with others, or disobey authority figures.
Unfortunately, this rage can become a self-fulfilling prophecy for the family. That’s because the family might simply dismiss the identified patient’s behavior as being “too angry” or “too dramatic” or “too emotional.” This maintains their notion that the individual is somehow broken and inadequate, reinforcing their scapegoating.
Growing Up Early
Some identified patients become incredibly self-reliant at a young age. They may excel in school or sports or start working early in life. They might leave the house as soon as they possibly can and embrace a very independent way of being.
In a sense, they’ve learned how to rely on themselves because nobody else has been reliable. They knew they had to take care of themselves and figure out how to solve the home problem because nobody else would do it for them.
Instead of praising this individual’s independence, the family will often complain that the identified patient is too detached or uninvolved. They will often blame the identified patient for “not thinking” of them.
What If You’re the Identified Patient?
It can be painful to realize that you essentially hold the dysfunction within your family’s dynamic. Because of this reality, you may have felt ostracized your entire life. You just didn’t exactly know why. In some cases, it’s possible you only now recognize that you were treated unfairly.
Regardless of your particular circumstances, being scapegoated is difficult. It’s normal to feel confused, angry, or sad. It’s also normal to question the kind of relationship you want to maintain with your family moving forward.
That said, it is possible to recover and heal despite your upbringing. Here are some tips.
Many identified patients blame themselves for their role. That’s because they have fully internalized their family’s beliefs about them.
If this applies to you, you likely believe that you are inferior or “bad” in some way. You might even believe that their treatment of you was legitimate.
Challenging these deeply-rooted beliefs won’t happen overnight. But you can start healing by practicing more self-compassion.
Taking care of yourself now may mean taking care of your inner child. Try to nurture the small child who was neglected, abused, or shamed. Try to imagine him or her and reflect on how innocent they were in the system. See if you can extend some kindness and love to your younger self. In doing that, your current self may start to heal.
Validate Your Feelings
You have a right to feel however you feel towards your family right now. Subsequently, trying to deny, suppress, or minimize these emotions often backfires.
Validating your feelings simply means honoring whatever feelings arise for you right now. Try not to judge yourself. Remember that you are only human!
If you find this recommendation challenging, it may be helpful to imagine that you are talking to a close friend. How would you respond if they shared a similar story to yours and told you they felt upset or ashamed because of their upbringing? There’s a good chance you would be nurturing and patient with their emotions- just like you should strive to be with yourself.
You are no longer a child, which means you aren’t completely dependent on your caregivers to take care of you. Instead, you can learn to trust yourself to ensure you meet your needs.
Setting boundaries is important in healthy families. But it becomes crucial and non-negotiable in dysfunctional family systems.
Boundaries can include physical, emotional, spiritual, and financial limits. For example, you may need to tell your mother that you will leave her house if she criticizes you. Or, you might tell your sister you will no longer loan her money until she pays back whatever amount she already owes you.
Keep in mind that boundaries often feel incredibly uncomfortable. But it’s one of the essential steps towards honoring your integrity.
Therapy can be an invaluable resource for identified patients. If you were dragged to therapists in the past, keep in mind that seeking your own treatment is a drastically different experience. This is treatment on your terms and without adhering to someone else’s agenda.
Therapy offers support, guidance, and coping skills that can help you heal from your past. While you can’t change what happened to you, you can learn how to live in a way where those memories no longer define you.
Likewise, therapy can help you if you’re struggling in your adult relationships. Interpersonal difficulties in adulthood often have origins in childhood. Addressing these issues- and learning how to deal with them- can help you feel more empowered.
When one person changes, the entire family dynamic shifts. This is inevitable, but it often feels highly distressing for the rest of your family.
For example, let’s say you’ve struggled with depression for many years. It began during adolescence, and your parents constantly begged you to “get better.” They often blamed you for being moody or disagreeable with the family, scapegoating you into the identified patient role.
Then, you attend a treatment program and start feeling significantly better. You make dramatic changes in your life and commit to bettering your mental health. You continue participating in therapy, taking medication, and engaging in positive lifestyle changes. You feel the best you’ve felt in years.
You might think your family would be proud of you (this is what they wanted!), but the opposite happens. They almost seem jealous or annoyed by your changes. They make snarky jokes about you needing to take medication or go to therapy. They still continue to blame you for being “so difficult” as a teenager. They even dismiss the treatment program for being overly expensive.
Unfortunately, these harsh and resistant reactions can be common. Your family might not be ready to embrace your changes. They might be perfectly comfortable having you be the “bad guy” or “broken child” as a way to redeem themselves.
Being the identified patient can be devastating for young children during their critical identity formation years. But the problems don’t just disappear once children become adults and leave home. Low self-esteem, feelings of isolation, and disconnect from others can impact how these adults function in all parts of life.
If you recognize yourself as being an identified patient, you deserve support and healing. You are not responsible for your entire family’s behavior. You are only responsible for doing your part in making the best decisions moving forward.