All in the Family: The Identified Patient

“Happy families are all alike; every unhappy family is unhappy in its own way.”

You only had to make it through the first chapter [first line, to be honest] of Anna Karenina to find this out–and there will be no quizzes assessing your knowledge of the novel after, so you’re home free now.

Despite Tolstoy’s assertion that unhappy families are distinctly unique, family systems work often finds a recurring pattern among them. When there is a disorder within the family, everybody plays a role. And, then, subconsciously, someone agrees to be the identified patient.

Someone–often a child or adolescent–takes on the family’s illness and acts it out, through drugs, alcohol, anorexia, bulimia, school refusal–through any number of unacceptable behaviors. This ‘sickness’ on the part of one of the family’s members may serve the role of distracting the parents from their own dissatisfaction with each other, protecting another sibling from parent anger, hiding a parent’s drinking, etc. This ‘patient,’ and the family response to him/her, throw people off the trail of the real problem.

See the identified-patient-handout for further clarification of the identified patient.

The Bronte family is well-known for some serious ‘mishegas,’ and one of their unspoken rules was that no one was allowed to leave home. As McGoldrick points out in Genograms in Family Assessment [see previous post], if one of the children should venture out, she developed symptoms, become the temporary identified patient, and was forced to return home. Clearly the identified patient in the Brontes served the purpose of keeping the family in tact and insular–and the symptomatic sibling acted out this profound dysfunction. In fact, the two sisters who died in childhood developed the diseases that would kill them during their first times away from home. Only one sister, Charlotte of Jane Eyre fame, actually had real relationships outside the family. And only she was able to marry.

But if you’re beginning to understand the dynamic of the identified patient, you will know that Charlotte’s ‘escape,’ coupled with this family’s beliefs about leaving home, had to end badly, and, sure enough, Charlotte became ill soon after her marriage and subsequent pregnancy and died a mere nine months after her marriage.

As is clear from the Brontes, families, like so many entities, fight change, especially so because change in one family member, given the interconnectedness of the system, will force change in other family members, and change is uncomfortable. Thus, should the identified patient start to break the bonds of illness that keep him in his place as ‘patient,’ the system becomes stressed, and the other parties work to keep the that member ‘sick,’ so that the family can continue to function as before.


Of interest:


I help adults and adolescents through the particular struggles of our time: tension between couples, parenting frustration, blending new families, separation and divorce, (un)employment, cancer, and loss. When relationships come to an impasse, I use mediation techniques to try to ensure that each party will have his/her needs heard and accounted for in a dignified way. In addition to talking, listening, and reframing, I utilizes the tools of metaphor, active teaching, role-playing, visualization, and hypnotherapy.for families and businesses, as well as in cases of divorce.

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