The Identified Patient is a concept where an individual in a family “acts out” in their behavior dysfunction coming from their family when it reaches a point where that patient can no longer tolerate it.
What does that mean?
Imagine you’re a child in a family where there is much more conflict and anger between your parents than there is cooperation and lovingness.
As you step out into the world, something we refer to as Separation, and you run into an obstacle or a victory, you look back literally and psychologically looking for attunement – meaning feeling that your parents are tuned into you vs. their being self-absorbed or caught up in conflict and animosity towards each other – and then for a combination of loving, reassuring warmth from your mother and encouragement, coaching and reassurance from your father.
When you receive that emotional, empathic attunement from a mom and focused (vs. generic, "Don't worry about" empty comments), coaching reassurance from a dad, you internalize it and then can move forward past the obstacle and further into the world with confidence that you can handle future adversity.
However, when instead of receiving selfless, attunement from a mom and reassurance from a dad, you pick up self-absorption in each of them and conflict between them, rather than your feeling psychologically strong and confident to push through and past the obstacle, you become triggered.
When you become triggered, you can react with anxiety internally and respond back to the world by either fight or flight or freeze, all of which make it difficult to master and push through and past the obstacle and develop resilience afterwards.
Many children who cannot internalize a sense of well-being and “everything will be alright” from highly conflicted and angry parents, have difficulty individuating (stepping out into it and landing in the world feeling safe, whole and confident) which causes them to feel increasing anxiety.
When the anxiety mounts because every time they look to their parents to empathically attune, emotionally connect with them and then coach and reassure them, they receive none of it or worse receive criticism or anger from them, that anxiety can begin to cross over into panic attacks, self-harm such as cutting, eating disorders, etc. to distract from and relieve the emotional pain, or drug and alcohol use to medicate and numb themselves.
Interestingly and not surprisingly, when they turn to drugs, alcohol, opiates and/or meth, etc. they are trying to emotionally parent themselves with the downer drugs like benzodiazepines, alcohol, opiates, fentanyl, etc. taking away their pain the way an attuned and loving mom would with calm, patient, compassionate empathy and with the upper drugs like meth, cocaine, amphetamine, crack, Adderall substituting for the coaching and encouragement of a dad (see: “Drugs as the New Parents”).
Sometimes when the child as a teenager or young adult, starts acting up and out in very violent, anti-social, or other ways it is not only a “cry for help” to their parents, but also a “cry for, ‘can you stop fighting and being angry at each other and focus on me, because I’m falling through the cracks, the world is passing me by, and I can’t move forward unless you get your act together!’”
Sadly, those cries for help and to have their parents’ stop their conflict and anger at each other are usually unheard resulting in that teen or young adult not evolving further or developing the skills to master the challenges from the world. In other words, rather than being able to “take the hit” from whatever the world throws at them and building tenacity, fortitude, stick-to-it-ness, resilience and eventually mastery, they remain developmentally stuck.
Occasionally, however, the combined love for their child and not wanting him or her to die is strong enough to wake parents up and cause them to begin to cooperate and work together – sometimes for the first time ever – in order to help that child. This usually requires a therapist and/or interventionist and rehab program, when drugs are the problem.
In that instance the child who is acting up and acting out has become the “identified patient” for a dysfunctional relationship between the parents and may distract them from their anger at each other and instead cooperate to save their child.
Years ago, when I was a practicing psychiatrist focused on individual, couple and family therapy I would occasionally ask teenagers if they had to make a choice between having their parents give them whatever that teen wanted or having their parents go from resenting and even at times hating each other to loving each other, most of the teenagers would pick their parents loving each other.
That is why you’ll sometimes hear from teenagers that they wish their parents would just get a divorce if all they seem to do is get angry each other.
Interestingly, when I have asked couples in conflict a similar question of what they would choose if it was between their partner doing whatever each person wanted or never having to feel that ice pick under the ribcage feeling of deeply hating the other person, most partners would choose never having to feel hatred towards the person they love.
That has caused me to believe that many relationships end not because people stop loving each other, but because they can’t stop hating each other.
It’s never too late to turn a dysfunctional family into a healthy functional one, but what it takes is for every member to care enough to commit to making it happen.
In the end, people don’t do what’s important to them, they do what they care enough about.
Sometimes the internalized sense that they would never recover from the death of an identified patient child is what causes dysfunctional parents to care enough to finally change.
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