The Identified Patient Phenomenon
Identified Patient Defined
Family systems therapy is a psychotherapy approach that acknowledges the intimate involvement of family in an individual’s mental health challenges. Much of the modality’s theoretical development was pioneered by author and psychotherapist Virginia Satir in the mid 1900s. As a theorist and practitioner, Satir studied the interactions between family culture and mental illness, and developed the concept of the ‘identified patient’. The term identified patient (IP) describes an individual who consciously or unconsciously manifests hidden family dysfunction and is consequently scapegoated (Ferenchick & Rosenthal, 2017). The dysfunctional patterns of group beliefs, behaviors, and communication are typically established by parental figures and may be rooted in generational or acute traumas (Minuchin & Fishman, 1981). Functioning as a manifestation of the family system’s underlying distress, the IP may exhibit overt physical, psychological, and behavioral symptoms. Unfortunately, their authentic expression can provoke members who are in denial about family issues and engender intense blame.
Sociological Context
The IP phenomenon can be best understood when contextualized within the constructivist view of reality. Social constructivism is a sociological theory which states that knowledge, beliefs, and values are organically created through interactions among people (Charmaz, 2014). More specifically, there exists a dialectical relationship between individuals and their larger social contexts, and shared reality originates from subjective interpretation of these exchanges (Berry et al., 2011). This creative process is often gradual and unconscious but serves to inform collective views of what constitutes truth. Similarly within families, issues of scapegoating and stigmatization can be reinforced by interaction patterns. For example, in situations where a child is the IP, the negative attitudes and treatment by parents are easily mirrored by siblings who internalize the adult’s behavior (McHale et al., 2012).
Psychotherapeutic Interventions
As Satir observed, an IP can be coerced by family members into psychotherapy treatment. However, because the unspoken goal is to keep dysfunction or trauma hidden, the system’s homeostasis comes to depend on the continued scapegoating of the IP (Asen, 2002). This can place the individual in a double bind whereby their physical and mental health challenges are deemed problematic, but the semblance of recovery encounters resistance. Fortunately, when a scapegoated individual enters psychotherapy there is an opportunity for their therapist to discern the broader influence of family on their symptoms, and ascertain whether to conduct treatment through a family therapy lens. Ideally this involves the participation of family members; however, this may not always be possible.
Family therapy models frequently utilize a non-pathologizing approach to treatment that encourages relational responsibility over causal blame attribution. Hidden family dysfunction is reframed as a developmental challenge and a catalyst for holistic change. For example, a 2016 study by researchers Patrika and Tseliou explored therapeutic techniques for transforming family belief systems. Analysis of initial sessions with six families demonstrated that therapists can begin this process by questioning the ‘truth’ of the IP’s deviance, aligning with each family member, continuously shifting the locus of blame attributions, and reframing the IP’s distress as a call to reunite the family (Patrika & Tseliou, 2016). These techniques demonstrate how shifts in communication can help to create more balanced, flexible cognitions. In alignment with the constructivist view of reality, relationships within families can be improved through new forms of dialogue and collaboration.
Sources
Asen, E. (2002). Outcome research in family therapy. Advances in Psychiatric Treatment, 8(3), 230-238. https://doi.org/10.1192/apt.8.3.230
Berry, J.W., Poortinga, Y.H., Breugelmans, S.M., Chasiotis, A., & Sam, D.L. (2011) Cross‐cultural psychology: Research and applications (3rd ed.). Cambridge, UK: Cambridge University Press.
Charmaz, K. (2014). An invitation to grounded theory. In Constructing grounded theory (2nd ed.), 1-21. Thousand Oaks, CA: Sage Publications.
Ferenchick, E., & Rosenthal, D. (2017). Identified patient in family systems theory. Encyclopedia of Couple and Family Therapy. https://doi.org/10.1007/978-3-319-15877-8_282-1
McHale, S.M., Updegraff, K.A., & Whiteman S.D. (2012). Sibling relationships and influences in childhood and adolescence. Journal of Marriage and Family, 74(5), 913-930. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956653/
Minuchin, S., & Fishman, H.C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press.
Patrika, P., & Tseliou, E. (2016). The ‘blame game’: Discourse analysis of family members’ and therapist negotiation of problem definition in systemic family therapy. European Journal of Counseling Psychology, 4(1). https://doi.org/10.5964/ejcop.v4i1.80
