Being the Identified Patient II

I wrote this post a long time ago and so many of my readers seem to be struggling with this I wanted to rerun it. Dance everyone!


If you cannot get rid of the family skeleton, you may as well make it dance. – George Bernard Shaw

Sometimes we are the family skeleton, the black sheep, the shame of the clan. Many times it’s because the clan is completely nuts. A dysfunctional family needs someone to focus on, someone to blame things on, someone to point to when things go wrong. In clinical settings, we call that person the “identified patient” or IP. It means that in a sick family system, the group has subconsciously elected one person to act out all the family sickness in a very overt way while the rest of the family acts it out in a covert way. Even if the IP tries to act “not sick,” the family will send messages to “get back where you belong” and set the IP up for failure.

Before you know it, the identified patient is acting out AGAIN and the family is shocked (simply SHOCKED! that the person they set up to be the IP is acting like an IP). The IP does the bidding of insanity for the whole family.

It’s not that the identified patient is any sicker than the rest of the family, in fact they probably aren’t, but they are the one through whom the family channels all of its “stuff.” The family dynamic is to keep things status quo, to keep its eyes trained on the IP.

I once went to conduct an emergency evaluation on a 17 year old girl who had not come home all night and was brought to the Emergency Room so that someone could figure out what was wrong with her. I was met by her parents, a father who had obviously been drinking and looked a lot older than he was due to alcoholism and a co-alcoholic, codependent mother who was angry and upset. During the evaluation I knew the kid was the IP in an alcoholic family and that the family was focused on her and her wayward ways and insolent mouth because they could not look at themselves and dad’s alcohol problem and mom’s complicity in it. I lived this scenario: all eyes had been trained on my acting out when my acting out was a normal symptom of being exposed CONSTANTLY to craziness.

They didn’t like it when I explained the problem was not her. I took her aside and suggested she go to Alateen and try to survive the rest of the year with her family. Her mother was furious at me that I was taking the kid’s side.

And so it is with the dysfunctional family system. The daughter’s behavior was actually a pretty normal and healthy response to craziness: ie I want to get out of here and not explain a thing to these people. But the family couldn’t see that and couldn’t see their own sickness which was much worse than any of the daughter’s issues.

Usually the one who gets help first in the family is the IP. They get out of the family and find out what is wrong because they are tired of being blamed for everything and everyone. Usually their acting out is a normal response to an abnormal situation and they want help.

It is actually a blessing to be the IP in the family. The rest of them can continue to be “maintenance crazy” which is maintaining a level of crazy that never needs help. Just crazy enough to avoid help.

But IPs have to get help. They are in the thick of the crazy and the crazies and it wears on them. Being the IP keeps you at a distance from the craziness and gives you a chance to get out of it. IPs tend to gravitate toward other people outside the family system who blame them for everything and keep the focus on them. But at some point the IP says, “I have had enough of this.” and move away from that person who is all too familiar (ie like family). Even if you’re not the IP, part of recovery is identifying who you were in the family and how you have carried that role into adulthood. See how your role in the family plays itself out in your current relationship and ask yourself if it’s time for a change.

Being the IP or the one that doesn’t belong can be a blessing. If you’ve never belonged, it’s easy to take a step in another direction. Take refuge in exile. It can be a good thing.

If you’ve been the IP, realize you’re never going to win their approval, so stop trying. You have a role to fill and they’re not going to be happy if you’re not filling it. If you’ve brought it into your relationships, chances are you will not be validated and acknowledged in those adult relationships either.

Stop seeking approval from people who don’t have it to give. Throw off those old messages…get rid of the negative messages from the family…get rid of “get back where you belong” everytime you try to save yourself. It’s okay. As the saying goes, “Explain nothing to nobody.”

You may be the family skeleton…the one they keep under wraps and try to explain away.

You may play a very specific role for them and they are going to be very upset when you step out of that role, but if you are the family skeleton: DANCE. 🙂

This entry was posted in family therapy, hero, identified patient, lost child, recovery, role, scapegoat, triad. Bookmark the permalink.

5 Responses to Being the Identified Patient II

  1. Coppergirl says:

    Wow! I really can relate to that poor young woman. I see myself at 17 there, same issues, alcoholic parents, I was essentially running the whole damn household at the time; cooking, cleaning, the lawn, the garden, you name it. Day after high school graduation, I was outta there, suicidal brother in tow. Had emotionally divorced myself from them at 10. Would pretend I was a prisoner in a concentration camp in order to stay sane. My poor brothers never escaped the pattern, always wanted nurturing parents that didn’t exist, and were destroyed by that. I wasn’t much of a parent, being traumatized by family, working, going to school, gone all day but I did a helluva better job than the folk that were supposed to be doing so. Kudos for telling her folks they were the problem.

    • Susan J. Elliott says:

      The PS to that story is that a few weeks later I was called to do a psych eval at the VA hospital. It was the DAD being treated for advanced liver disease. I knew he was bad but didn’t know he was THAT bad. The mom was there that day and SOBER. The woman who was so crazed and wanted to hit me the night they brought the daughter in and argued up a storm with me was looking very sheepish. I took her aside and said, “I know you’re hurting too and I suggest you go to Al-Anon and figure out how to help him before he kills himself with booze.” She was very peaceful and thankful. I never saw any of them again but I hope they all got the help they needed. Because I was the IP in my family I had a lot of empathy for teens who were running away from alcoholic families. Other clinicians would have given the kid some diagnosis or something and I refused. I like to think I helped a lot of kids during my time as an ES clinician. I knew their pain very very well.

  2. Coppergirl says:

    Interesting end to story. I sincerely hope all involved got the help they needed. About a week after our family fragmented; me and bro up north, dad to his next job site, stepmom#1 got fired from her job and fell down stairs, breaking her arm. No one left to caretaker her. She married for a third time, moved to a Mexico somewhere. One of her kids married a drug dealer and at some point, came down with rheumatoid arthritis, the son moved to the Phillipines, married a Phillipina whom he probably abused as I doubt his behavior changed any. I raised bro for a number of years, doing the best I could. Dads eventual third wife shamed him into parenting his son and it was the downward spiral for bro. Bro dropped out, got into a scary drug scene, dad shipped him off to the military where bro got into trouble. Dad was an overaged party boy at this time. Bro eventually got his crap together but was tragically killed in a motorcycle crash. Dads marriage and businesses crashed and I wound up supporting him for two years. Hard as he was an active alcoholic. I regret now being kinda mean to him but at this point, I really had a hard time dealing with folk who refuse to take responsibility for their actions in life. Have that same attitude to this very day. I married and left the area to get my Doctorate. Sure hope that 27 year old moved on, worked her way up and out, way out.

  3. sophia says:

    Hi susan, i am trying to follow all your posts, videos, etc. I am trying not to miss anything, because i feel that it helps me a lot. Thus, i thought it would be very good if you post the links of other sites (youtube, etc) on here whenever you post/include anything there as awell.. Maybe you are already doing it on this site, and i may have missed it. But again, if you post a referral link on this blog on the day you post something, it would be really very helpful to us. I am sure all your followers would like to be led to the other sites as long as they can find you there 🙂 for example, i had the chance to listen your conversation on voiceamerica thru the link you have included as a response to a user on this site. If i have not go thru all the comments (i try to read all the comments as they also help a lot), i have not had a chance to listen it.
    (As an update; i started journaling everyday, finished wwl2m, started codependent no more. Observing myself at the same time. Watching your videos as well. I feel like i lost all my feelings, but again i know it will be good. I am working. And i will build myself, i will work. I have not started the affirmations as i am trying to understand what my affirmations should be, and i still cannot build my relationship with the outer world (i dont want to go out, i have not started exercising, i have not started looking for hobies etc) but i believe i will start doing and find a way. I just wanted to add these after my suggestion above just to share with you and other users where i am at now).
    Btw, whenever i watch your videos or listen to you, i find you SO SMART and your humor is UNBELIVABLE 🙂 english is not my mother tounge, and i cannot understand/laugh at american jokes/humor that much, but you really make me smile so much of the time. And i am thinking that none of the men in your past or friends had the ability to dance with your intelligence capacity ( i am not even counting your emotional capacity). I know that you are at a totally different phase now, but again i wanted to let you know this. Yes, we have so much things to overcome and we have made bad selections, or we made people treat us badly or something was not right etc. but again, if you werent deficient, again your smartness and emotional highness would have been a problem for both men and women. Only someone, as you mentioned, very very healthy and self confident, could have loved you sincerely. Because you are DIFFERENT. You can have defects etc. but again you are different than them. Who else, could have written such books and try to help people as much as you do? Fairly so little, so so little. I am always praying for you. As i said, you are a STAR, you really are. I wanted to write these not on my journal but on here today to show my graditute. Have a nice day. . Xoxo.

    • Susan J. Elliott says:

      Thank you. If you go up to the black bar, there is a tab GPYB/GPYP/GBOT Resources and that lists all the places you can find links to the videos/articles etc. 🙂 I also put most of the links at the bottom of every Psychology Today post.

      Thank you again and keep up the good work. Please start the affirmations asap….little by slow, but you can do this!!!

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