Early in the development of family therapy theory, authors used the term “identified patient” to describe the family member whose behavior brings a family into treatment. This is usually one of the children, but not always. It is the person who has acted out enough to cause the parents to seek help or to get the family referred for treatment.
Identified patients show up in couple treatment, as well. The identified patient might be the “troublemaker”, the one whose behavior is the most noticeably inappropriate and irritating. Or less often the identified patient is the one who seems more “needy”. A sure method for knowing which partner in a couple has assumed the identified patient role is recognizing which is more difficult to empathize or identify with.
In couple therapy, it is common that both partners are pointing at the other as the identified patient, i.e., “All of our problems are your fault.” This may manifest as one of the partners accusing the other of being more immature or more obviously in need of help, while the other takes a tone of superiority or innocent victimhood. One draws the therapist’s intervention, while the other is “better behaved”.
I had a supervisor who described this structure in couple relationships as “one partner robbing the bank, while the other is driving the getaway car.” What he was saying was that both partners are equally responsible and equal participants in creating the conflicts in the relationship, even though their roles look quite different.
The therapist in this configuration can feel tremendously pulled toward identified patients, through either annoyance or sympathy. They can be very good at getting our attention. Avoiding the identified patient trap is necessary in order to clearly see the nonconscious purposes of both partner’s roles in creating dramas that will bring unmetabolized losses, wounds and traumas to consciousness. Cases in which one partner truly has a medical or psychiatric disorder should be addressed with referrals to other professionals who can specifically treat those disorders in order to avoid relating to that partner as the identified patient in the couple treatment.
The skilled therapist must work to develop a deeper–and equally balanced–understanding and empathy for both partners’ contributions to their repetitive conflicts. Perhaps the identified patient played the same painful role in their family of origin. Perhaps there are feelings tied to being a “bad guy” or “good guy”. Perhaps one of the partners had to be the perfect child in their family. Perhaps one of them is so terrified of having any bad feelings that their system has forced one of the partners into acting out the painful feelings of both.
Sometimes–although rarely–we encounter a partner in couple treatment whose “bad guy” role (or even “helpless victim” role) in the marital difficulties is an indicator that they literally cannot safely participate in couple treatment. I will address this phenomenon in the next post.