Are you the identified patient in your family?

I was at The Berkeley Bowl the other day when a woman stopped me in the produce section.

(Side note: for any of you not from the Bay Area, The Berkeley Bowl has to be one of the best local grocery stores on Earth and ever since I moved here 9 years ago it’s been one of my favorite parts of Berkeley. If you ever get the chance, check it out!).

“You’re the Black Sheep therapist!”

Me (holding a half-filled bag of kiwis and looking around to see if she was talking to someone else): “Oooh, yes, me? I guess I am?”

Her: “Yes, cool! I’ve seen your stuff on Facebook. So what exactly is a Black Sheep again?”

I put my kiwis in my cart. And she and I had a lovely chat where I explained more about who I work with. And what exactly I consider a “Black Sheep” to be.

I told her, that, while the term “Black Sheep” perfectly encapsulates who I work with, clinically speaking and interchangeably from a terminology perspective, the folks I do my best work with see themselves as the “Identified Patients” of their family system.

Identified Patients are considered to be/consider themselves to be the “other” in their family system.

Identified Patients are often the first people in the room to nod their heads when the term Black Sheep is said.

You say Scapegoat, they say YES.

Identified Patients disproportionately identify with, say, The Orphan Child archetype.

They know what it is to feel lonely, unsupported, and possibly alone.

Identified Patients can come from abusive, dysfunctional, and chaotic family backgrounds where early childhood adversity was the major theme.

And Identified Patients can also come from families that weren’t so outwardly dysfunctional.

In today’s post, I want to share a little more with you (like I shared with the lovely woman at The Berkeley Bowl) about what the term Identified Patient actually means, why this phenomenon happens in family systems, and what your choices are to take care of yourself if you see yourself in this description.

What does it mean to be the identified patient in a family?

“The identified patient sacrifices himself to maintain the sacred illusion that what the parent says makes sense”, and that “the identified patient exhibits behavior which is almost a caricature of that loss of identity which is characteristic of all the family members”. – Gregory Bateson

The term “Black Sheep” isn’t a clinical term you’re going to find in the DSM or a counseling psychology textbook. But Identified Patient is a clinical term and one you’re apt to hear.

Identified Patient is a term that emerged from the work of famed polymathic thinker, Gregory Bateson, in his 1972 work on family homeostasis – The Bateson Project.

In the field of family therapy, the term Identified Patient is used to describe what we might call the “symptom bearer” of the family system.

What’s a symptom bearer?

Someone who, because of a variety of variables, expresses the unresolved and unmanaged psychodramas and strong (often dysfunctional) emotions of the group.

One interesting idea in family therapy also believes that the Identified Patient of the family system can also hold intergenerational symptoms from the lines that came before them.

So not just the immediate dysfunctions of the nuclear family unit, but also, potentially, the unresolved pains and sufferings of their grandparents, great-grandparents, and so on.

An identified patient is often identified as the problem and frequently brought to therapy for “their problems.”

A classic example of this in the family counseling space is when parents bring their adolescent into therapy where the primary wish is to focus on “fixing” that person.

But, in fact, the work lies with the whole family system. Not just that one person.

Yes, that one person may be outwardly expressing symptoms and signals that look more obvious, more in need of tending to, but that person is expressing the pain and dysfunction of the whole system.

Their problems didn’t emerge in a vacuum and they won’t get fixed in a vacuum.

The identified patient’s “problems” are reflective of unresolved systems problems and they are serving the role of the proverbial canary in the coal mine trying to warn off larger, problematic issues in the group entirely.

Why does this happen in families?

“It is possible You are the consciousness of your unhappy family, Its bird sent flying through the purgatorial flame”. – TS Eliot

Why in a family that would otherwise claim and in reality probably does love and want to support each other, would someone implicitly or explicitly be identified as or have to take on the role of the identified patient?

Think of it this way: when a family system is psychologically and emotionally healthy, strong, resilient and robust, problems can arise and be tended to with resolution, responsibility and resolve.

When a system is not healthy enough to tolerate and metabolize the stressors and painful experiences of the individuals or any iteration of individuals in the system, when the psychological strength and skills are absent to deal with this, the family system unconsciously “outsources” the anxiety, pain, and frustration they are going through.

What do I mean to outsource?

Well, it’s like having a really crappy day at work and then coming home and yelling at your partner even though they did nothing wrong.

You “outsourced” your painful feelings onto a person who was not the cause of the problems because you couldn’t regulate yourself.

You couldn’t tolerate all the big hard feelings inside of you so you placed it outside of yourself in order to cope.

It might feel good for a little bit to get that big energy out of your system but ultimately it’s not great for your relationship bond with that person.

The same thing can happen with family systems.

When a system can’t cope with what’s going on, especially over time due to unlearned tools, skills, and ways of being, they can unconsciously (and not intentionally) outsource their big, unresolved feelings onto another person in order to “feel better.”

Look, I’m not trying to demonize or disparage anyone or any family system.

In reality, almost all of us outsource our frustration from time to time. (Just ask my husband.)

Buuuuut, when this outsourcing happens regularly, consistently, chronically and when there are distinct power differentials involved (parent over child for example), this outsourcing becomes a bigger, potentially detrimental issue.

Family systems who can’t tolerate their painful realities “take care of themselves” by outsourcing grief and concern to one member of family, and in this way they think they’re taking care of themselves.

But, in reality, it doesn’t actually help the system as a whole get healthier and it certainly makes the experience of the person receiving the outsourcing – the Identified Patient – harder.

What are some examples of being the identified patient?

“Adolescents are not monsters. They are just people trying to learn how to make it among the adults in the world, who are probably not so sure themselves.” – Virginia Satir

There are as many iterations of what it can look like to be the Identified Patient of the family system as there are unique families.

But here are a few examples of how this Identified Patient archetype may manifest:

[Parent to teen] “You’re so angry all the time! What’s wrong with you? You’re such a mean older brother. Why can’t you just be nice like your sister?”

[To the family counselor] “Savannah’s high all the time and she’s failing most of her classes. We just don’t GET it. Her sister was the valedictorian, senior class president, and she just got into Stanford. We don’t understand why Savannah can’t act like her sister.”

[To the child] “Dad’s just being Dad. That’s just how he is. He’s just joking when he says things like that. You shouldn’t be so sensitive. You’re such a snowflake.”

[To the therapist] “We just don’t know where we went wrong with Sam. Both of us went to Ivy’s, my wife is the first female CEO at her firm, our house is covered in books, and all he wants to do is sit in his room and play video games with friends he doesn’t even know in real life. It’s like he’s not even our child!”

In each of these scenarios, one person is maligned for their experience, seen as being “wrong” somehow for acting, thinking, and feeling the way that they do.

This – being targeted and made wrong even if in so-called service of trying to help them – is a hallmark of the Identified Patient’s experience.

Will things change? Will I always be the identified patient of my family?

“It is now clear to me that the family is a microcosm of the world. To understand the world, we can study the family: issues such as power, intimacy, autonomy, trust, and communication skills are vital parts underlying how we live in the world. To change the world is to change the family.” – Virginia Satir

If there’s one thing I learn the older I get, it’s never say never. Because there is always the possibility for change.

Even in dysfunctional family systems.

Family systems are living, breathing, and alive in a way.

Alive, dynamic systems and organisms always have the possibility to change.

Sometimes this means the system itself gets healthier.

Like when, ideally, a whole family gets their butts into therapy with a truly great family counselor and does the hard and generationally impactful work of seeing what is and developing tools to function more healthily and responsibly.

And sometimes this change occurs when the Identified Patient removes themself (or distances themselves) from the system in order to get healthier.

Either way, it doesn’t mean that you ARE the Identified Patient of the family system objectively and forever after. And that things will always feel the way they feel.

You have options. And there is always room to change.

Both how you perceive yourself and also how your family perceives you and how the family functions as a whole.

So how do I take care of myself if I’m the Identified Patient?

“Feelings of worth can flourish only in an atmosphere where individual differences are appreciated, mistakes are tolerated, communication is open, and rules are flexible – the kind of atmosphere that is found in a nurturing family.” – Virginia Satir

Again, you have choices.

I want you to consider the idea that a family system – be it healthy or dysfunctional – has a certain kind of dance going on.

Locked in step, the unit “dances” in a certain way. Everyone is doing the steps they know how to do. The steps they’ve been unwittingly trained to do.

Now, in an ideal world, would we get a dance teacher in there to choreograph better and improved steps for the whole unit?

Yes, of course! And this is ideally what family therapy is about.

But consider this, too. In a dance, any kind of dance, if one person changes their dance steps, the dance changes.

So, if you see yourself in the Identified Patient description but there’s no way your family (at least at this time) is going to go to family counseling, remember that you still have some agency and control.

You can be the person who changes your dance steps.

When you change your dance steps, even if others don’t, something about the dance will change.

And if you identify as the Identified Patient and you want to take care of yourself, consider that the biggest way you can change your dance steps is through boundaries.

Boundaries about how you see yourself. How you let others speak about you, treat you. The proximity or distance you have with a system that’s not healthy and supportive and hell-bent on seeing you as an Identified Patient.

You can best take care of yourself by clarifying your own boundaries. Learning how to assert them. Asserting them. And then taking care of yourself when the ensuing emotions and responses rise up in you.

Look, learning how to recognize, clarify, assert, re-assert, and re-negotiate personal boundaries with challenging people (especially in our family of origins or the families we marry into) is a huge, complex and very emotional topic.

And it’s something far bigger than this one article can tackle.

If you see yourself in the term, Identified Patient, I also highly encourage you to check out my other posts below.

They may speak to you and, I truly hope, provide you with a little bit of comfort, camaraderie, and hope.

Healing the Identified Patient Role Through Family Systems Therapy

When you sit in therapy describing how you’re always labeled the “difficult one,” the “too sensitive” child, or the family problem despite seeing dysfunction everywhere in your family system, your therapist helps you understand that being cast as the power of being the black sheep in your family often means you’re actually the truth-teller whose sensitivity threatens the family’s denial system.

They introduce you to family systems theory, explaining how families unconsciously designate one member to carry collective symptoms. Your anger might be the only anger allowed in a family that suppresses emotion. Your addiction might express generations of unprocessed trauma. Your “failure” might represent the family’s disowned dreams.

The work involves mapping your family system—who holds what roles, what emotions are permitted or forbidden, what stories maintain homeostasis. You begin recognizing how being scapegoated served the system: if you’re the problem, no one else has to change.

Your therapist helps you see that Identified Patients are often the family’s most emotionally attuned members. Your sensitivity that gets labeled “too much” is actually accurate perception of dysfunction others can’t acknowledge.

Together, you work on differentiating—developing a self that exists beyond family projections. This means grieving the fantasy that if you just changed enough, your family would finally see and love the real you.

You practice what your therapist calls “changing your dance steps.” When family members try to cast you in familiar roles, you respond differently. Not with rebellion (which keeps you in the dance) but with calm non-participation.

The goal isn’t necessarily estrangement but conscious choice about engagement. Some Identified Patients maintain limited contact with new boundaries. Others need complete distance to heal. Either way, you’re no longer available to be the repository for your family’s unprocessed pain.

Here’s to healing relational trauma and creating thriving lives on solid foundations.

Warmly,

Annie

“All strong souls first go to hell before they do the healing of the world they came here for. If we are lucky, we return to help those still trapped below.” – Clarissa Pinkola Estes, PhD

Additional Articles:

• The Power of Being “The Black Sheep” In Your Family.
• Remember, it was always an attempt to help yourself…
• A Bittersweet Happy Ending: Creating Your Second Chance Family-Of-Choice
• Brittle, Broken, Bent: Coping With Family Estrangement.
• Siblings cope with trauma differently. Here’s why.

Medical Disclaimer