Identified Patient

the family reunion

scapegoat by Gary Alexander

Identified patient (IP) is a form of dysfunctional parenting where one child, usually selected by the mother, is forced into going to therapy while the family’s overall dysfunction is kept hidden. The term is also used in the context of organizational management, in circumstances where an individual becomes the carrier of a group problem (also known as scapegoating).

The term emerged from the work on family homeostasis in the Bateson Project, a ground-breaking collaboration organized by English social scientist Gregory Bateson in the 1950s and early 1960s. Bateson described it as a way to identify 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.

American social worker Virginia Satir, considered the ‘Mother of Family Therapy,’ 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 they have been carrying. In such circumstances, not only the IP but their siblings as well may end up feeling the benefits.

Scottish psychiatrist RD 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 behavior – ‘playing’ sick to prevent worse things happening in the family, such as a total family breakdown.

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 that requires the constant care and attention of the parents. In ‘Dibs,’ an account of a child therapy, psychologist 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.’

A child may be regarded as a bully and a troublemaker in school and labeled a ‘problem child,’ when he may in fact be expressing conflicts and problems, such as abuse from home, by acting out and being ‘bad.’ Gregory Bateson considered that sometimes ‘the identified patient sacrifices himself to maintain the sacred illusion that what the parent says makes sense,’ and that he ‘exhibits behavior which is almost a caricature of that loss of identity which is characteristic of all the family members.’

Swiss philosopher and psychiatrist Carl Jung independently concluded that a neurosis (neuroticism) ‘comes from the totality of a man’s life…from his psychic experience within the family or even his social group,’ and saw himself as something of a case in point: ‘I feel very strongly that I am under the influence of things or questions which were 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.’

‘The anti-psychiatry movement of the Sixties…proposed the theory that it was families that were mad rather than simply the individuals who were scapegoated by them as the ‘sick member,’ thereby extending the original boundaries of the IP concept. ‘From this position, it was a short hop, given the ethos of the Sixties, to doubting the normality of normality itself…the mad were the super-sane.’ Laing might insist overtly that it is ‘not necessarily the case that the person who is ‘out of formation’ is more ‘on course’ than the formation. There is no need to idealize someone just because he is labelled ‘out of formation.” In practice, however, he and his followers tended to claim that ‘more often than not, a person diagnosed as ‘mentally ill’ is the emotional scapegoat for the turmoil in his or her family or associates, and may, in fact, be the ‘sanest’ member of this group…the least disturbed member of the entire group.’ Later family therapists would insist by contrast that no one family member should be supported to the exclusion of the others. British therapist Robin Skynner said, ‘You mustn’t take anyone’s side….That’s why I believe the ideas of R. D. Laing and Cooper have done a lot of harm. It’s natural, from an emotional point of view, to side with the scapegoat, but…it doesn’t work. Supporting only the scapegoat makes the rest of the family less secure, more paranoid, even less able to ‘own’ their bad feelings.”

In T. S. Eliot’s play ‘The Family Reunion,’ the protagonist is told, ‘It is possible You are the consciousness of your unhappy family, Its bird sent flying through the purgatorial flame’, and comes to see his life as ‘a dream Dreamt through me by the minds of others.’

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