What It Means To Be The ‘Designated Patient’ In Family Therapy

In many families, there’s a shared but unspoken understanding about who they collectively consider “the problem.”

It might be the teenager acting out, the parent with depression or the sibling struggling with addiction. In clinical terms, that person is often called the “designated patient” or “identified patient” — the individual whose behavior, emotions, or symptoms are seen as the root of the family’s distress.

But as family therapists emphasize, this role rarely forms in a vacuum. The designated patient is usually expressing — often unconsciously — something the family system as a whole can’t address directly. Their symptoms become the family’s signal flare.

“In typical family therapy sessions, the term ‘designated patient’ or ‘identified patient’ is used to describe the member of the family whose behaviors, emotions, or symptoms are problematic for the family,” said Dr. Jeffrey Ditzell, a New York-based psychiatrist. “Often the family will be seeking therapy as a result of this member’s maladaptive behaviors or issues.”

He adds that focusing on one member can obscure a larger truth: “In most cases, the distress of the designated patient is a possible signal of stress, dysfunction, or inequity within the entire family system.”

That means the “problem person” isn’t necessarily sick — they might simply be the one expressing pain on behalf of everyone else.

Family systems theory, developed in part by psychiatrist Murray Bowen in the mid-20th century, holds that families function as interdependent emotional units. In this framework, one person’s anxiety, anger or depression doesn’t belong only to them — it reverberates through the entire group.

“The term ‘designated’ or ‘identified patient’ refers to the member of the family who holds and acts out the stress of the family system,” said Emily Waitt, LMFT and founder of Kincove, a Los Angeles-based adolescent mental health center. “This person is often labeled as the source of the family’s problems. However, the identified patient is a symptom, not a cause of family dysfunction.”

In other words, what looks like one person’s pathology may actually be the family’s collective anxiety made visible. Research in family therapy has long supported the notion that symptoms that emerge in one person often serve a regulating function, keeping deeper conflicts or fears from surfacing in the group.

As Waitt notes, families often form this dynamic without realizing it. “Typically, families assign this role to one member to externalize the problem and avoid the shame associated with their role in the family system,” she said. By projecting distress onto one individual, the rest of the family can maintain a sense of equilibrium — even if it’s an uneasy one.

But that equilibrium comes at a cost. The identified patient bears the emotional burden for everyone, often at the expense of their own well-being.

When a family finally seeks therapy, it’s usually because of the designated patient. The family may come in saying, “We need to fix her,” or “He’s the problem.”

At first, that can seem like progress. But experts caution that when therapy focuses solely on the identified patient, it risks reinforcing the same dynamic that caused the problem in the first place.

“The singling out of a designated patient within the family can have negative results,” said Ditzell. “The ‘problem’ member may be unfairly blamed or shamed, or ultimately isolated from the rest of the family.”

Roma Williams, LMFT of Unload It Therapy echoed that concern. “The ‘designated patient’ is the person a family points to as the problem,” she said. “They’re often the one who gets pathologized and diagnosed — oftentimes because that’s how insurance billing requires it. In practice the identified patient isn’t the only one carrying issues. They’re usually the symptom-bearer for the larger family system, the squeaky wheel so to speak.”

Williams adds that this setup offers short-term relief but long-term harm. “It can create a false sense of stability because it’s easier to blame others than deal with our own stuff.”

That avoidance can become self-reinforcing. The more one person is labeled the source of trouble, the less incentive the family has to look at its own patterns of control, communication and avoidance.

For the person cast as the designated patient, the experience can be deeply isolating — and its effects can last well into adulthood.

“Being the identified patient means that you bear the problematic symptoms of the family,” Dr. Nari Jeter, LMFT said. “Your problems — eating disorder, substance abuse, acting out, depression, anxiety — are the reason the family needs help or is seeking therapy. You are to blame for the family’s stress and dysfunction, but it is often because of the family dysfunction that you are showing these symptoms.”

In that dynamic, even attempts to help can reinforce shame. Jeter adds, “Being labeled ‘the problem’ early on from people we are supposed to love and trust further cements that role and view of oneself.”

Over time, this can shape a person’s identity — especially if the family dynamic remains unacknowledged.

Nilisha Williams, LPCC-S, founder of Ace Wellness, said that people in this role often internalize blame and guilt. “The identified patient may develop low self-esteem, chronic guilt or shame and difficulty trusting others or forming healthy attachments.”

She adds that the pattern doesn’t necessarily stop when someone leaves home. “Some individuals may even recreate the scapegoat role in friendships, workplaces, or romantic relationships,” Williams said.

The most effective family therapy approaches work to dismantle this “problem person” narrative and invite everyone to the table. Healing, experts say, starts with shifting the focus from the individual to the system.

“The first step is shifting the perspective from ‘this person is the problem’ to ‘the family system is struggling,’” Waitt explained. “The goal is to move the focus from blame toward shared responsibility and healthier ways of relating.”

Family therapy research supports this approach, as change becomes more sustainable when all members are involved in exploring patterns of interaction, rather than focusing on “fixing” one member. As Ditzell summarizes, the designated patient’s symptoms are “a shared reflection of the entire family system’s health.”

Williams agrees. “I help families shift the lens from ‘What’s wrong with this person?’ to ‘What’s happening in our system that creates this pattern?’ Once families see the bigger picture, they can start addressing underlying issues — communication breakdowns, unresolved trauma and boundary-setting.”