The identified patient and a family’s truth

In family systems theory, we learn about this notion of an identified patient within a family. I remember my professor specifically encouraging us to watch for these people in the families we work with. They are the ones who present to the world as diagnosable. They show up as depressed, anxious, suicidal, oppositional, lonely, or sullen. They’re the ones on the margins of that family Christmas photo. The difficult ones. The ones who haven’t gotten the memo about how this family works. The ones who just won’t play along, get with the program.

The messy ones. The troublemakers. The rabble-rousers.

My professor told us that these symptom carriers will often be the truth-tellers, the ultimate family healers.

Our identified patient?

At the time, I remember experiencing such dissonance with this idea. You see, this notion of the identified patient described my younger brother Tom nearly perfectly.

And I remember being so frustrated with Tom throughout much of his abbreviated life. I wanted him to play along with the unwritten but clearly implied Duffy family rules. I wanted him to put down the pencil that created the deeply grim, disturbing artwork on sheet after sheet of typing paper. I wanted him to stop using. I wanted him to reflect to the world that everything was perfectly fine in the Duffy household.

“Just be normal, man. Go to school. Get a job. Cut your hair, goddammit! Why is that so hard for you?”

I think we all wanted that for Tom, or rather from him. Just be normal. Or at least act that way. The rest of us thought that would be best. We were certain he had no idea what was best.

So my professor had to be wrong. Tom couldn’t have been our identified patient, our truth-teller. He was a mess. He was the one who needed help. The rest of us, we were good.

It took a long time for me to recognize how wrong I was.

A case study in truth-telling

When I think about this identified patient thing, I often think about David (not his real name), a 17-year-old referred to me a few years ago. Initially, I had a talk with David’s parents. They described a disturbing pattern of self-destructive behavior. David took wild risks with his body and his mind. They told me about drinking to excess, snorting cocaine and taking LSD and other hallucinogens recklessly. He would walk along the ledges atop skyscrapers here in Chicago, deadly balance beams, just to feel the thrill. Maybe to press their buttons too. He did post pics on Instagram.

David didn’t deny any of this. But he also told me he thought his parents missed the most important part of his story.

David told me overtly he didn’t think his family was okay, at all. And he didn’t believe anyone noticed but himself. He thought his parents lived heartbreaking, lonely lives. He felt the same about his grandparents as well. He told me that his brother and sister, both rock star scholar-athletes, were also living similar quietly painful lives, wrapped in the masks of their ridiculously impressive resumés.

I remember feeling a familiar jab of discomfort with that last notion. In retrospect, that nudge was telling me that in my family, I was one of those siblings hiding behind that resumé.

For a while, I felt like David was deflecting. He wasn’t in fact performing in school, and a lot of the time he simply wasn’t showing up. He was oppositional and difficult, and not taking accountability for his actions. His behavior was incredibly risky, just like his parents described. They were right about all that.

Then, just by chance, the pandemic hit. My work with David went from in-person to virtual. I remember being concerned that the screen provided him too handy a hiding spot from me, likely to perpetuate his risk-taking or opting-out behavior.

In the first virtual session, as we were just getting oriented to this new way of doing therapy, I noticed a guitar hanging on David’s wall behind him.

“Hey, what’s with that guitar back there? Do you play?”

“Oh, that? Yeah, I play a little. Not that good really. It’s nothin’.”

“Well, would you mind playing me something?”

Just watching him tune up, I could feel my heart quicken. Somehow, watching this kid, I knew something special was about to happen.

“I’ll play an original, K?”

Yeah, that is in fact OK, David. That’s freakin’ perfect. I tried to tamp down my clinical enthusiasm.

Well, David turns out to be an amazing guitarist. He played this stunning classical piece so beautifully I nearly cried.

“Dude, that is gorgeous. What’s it about?”

Without missing a beat, “Family. Fucked up family.”

And off we went. David told me all about the pain of family, of his family. He did so while playing plaintive classical guitar behind his voice, very dramatic. And unbeknownst to David, he presented me with a master class in multigenerational familial pain, and how that emotional distress can trickle down a family tree so easily if not tended to.

And the more we talked about it, and the more I validated his point of view, the better David felt. He told me something interesting recently. Last time we talked, he told me he felt hopeful for the first time in his life. And at the end of the conversation, he said, “You know, the better I feel, I think my whole family feels better too. It’s like everybody’s getting better.”

These identified patients are important people. If we slow down and pay attention, they can help heal us all. That’s not hyperbole.

That’s truth.

The identified patient explained

You might wonder how and why this identified patient phenomenon happens in families. It involves psychological mechanisms we may not be very aware of. First, we are inherently highly resistant to change. And in families, change often comes from unearthing uncomfortable secrets, secrets that carry truth. And we all know that keeping secrets is so exhausting. We wouldn’t bother, collectively, if the family secret, the truth, didn’t pose such a profound threat.

After all, secrets hold power only when they’re secret. Left unspoken, they become more malignant, year after year. Identified patients show up as a clarion call that, uncomfortable as it may be, change is necessary. Secrets need to be revealed.

It’s requisite.

And second, deep below the surface, we know our family truths, and if they’re dark enough, we find a way to actively resist inviting them to the surface. Because once those truths see the light of day, we know they’re unlikely to return to the shadows quietly.

So instead, I find we subconsciously identify the most keen and sensitive among us, and we unwittingly project our collective traumas onto them. Then, their pathology, their illness, becomes the family’s focus. And as they carry that emotional load, so-called crises based on their sickness, their depression, anxiety, poor grades, obstinate and dangerous behavior, and drug use show up frequently enough to drain family resources.

We fill our time with worry and concern, treatments and medications, interventions, emergency school meetings and, often, hospitalizations. Major distractions from the long-standing familial pain underneath. With those distractions, the family system remains balanced, I suppose, but still unwell.

I’ve learned that these mighty truth-tellers, like Tom and like David, often carry generations of their family’s emotional burdens on their backs. I watch for these people now. They are often the very teenagers and young adults that are referred to me. They are the ones encouraged, even threatened, to brighten up or fall in line.

I’ve also learned these identified patients are precious, sensitive souls. Too often ignored or dismissed as annoying or disruptive, they carry such an important well of wisdom. If we really listen and attend to them, they can provide us a roadmap toward healing, not just alone in this moment, but soothing the weight of generations of familial pain.

Looking back, Tom was our family truth-teller. He carried the pathology of the Duffy’s for the entirety of his 34 years. In his own way, through his words, behaviors and actions, he tried to warn us that our family was not well. Even after he died by suicide we still didn’t get it. Because we still thought he was the one who didn’t get it.

Carrying the mantle

Slowly, over the years, I began to hear Tom, like a whisper at first. Over time, doing the work I do and attending to the multi-generational patterns in my family - the harsh judgments, the withholding of affection, the deep anxiety and darkness - his voice became louder to me, and ever more clear.

We could not hide in the shadows and pretend and lie about who we were and be a healthy family. We had to live the truth: the good, the bad and the ugly of it. All of it. Once I could finally accept all that, I began to hear Tom out loud.

And ever since then, I do periodic gut checks with myself. In an attempt to carry that truth-teller role torch, I find myself determined to make my generation the last to carry the bulk of that weight. And man, I hope I’m doing Tom proud. I hope he knows, somewhere out there, I finally hear him.

Uncomfortable as it might be, I think we all need to take a look at the roles we play as family members. If more of us give voice to our familial truths, we can spare the pain of those identified patient truth-tellers, as well as that of generations to come.

So please, take a long look at your own family. Who is the rule-breaker, the problem child, the truth-teller? Remember their sensitivity, and the power they carry for change. Place your fears aside and listen to what they have to say. Trust them. And give them permission to do their work and heal your family.

You’ll all be so much better off, from this moment all the way out to the horizon.