In countless Canadian households, an unspoken agreement exists about who carries the label of "the problem" within the family unit. This individual might be the rebellious teenager, the depressed parent, or the sibling grappling with addiction. While they appear to be the source of family turmoil, mental health professionals reveal they're often expressing something much deeper.
The Designated Patient Phenomenon
In clinical terminology, this family member is known as the "designated patient" or "identified patient" - the person whose behaviors, emotions, or symptoms become the focal point of the family's distress. According to Dr. Jeffrey Ditzell, a New York-based psychiatrist, families typically seek therapy because of this member's maladaptive behaviors or issues.
However, focusing exclusively on one individual often masks a crucial reality. Dr. Ditzell emphasizes that the designated patient's distress usually signals stress, dysfunction, or inequity within the entire family system. Rather than being inherently sick, this person might simply be expressing pain on behalf of everyone else.
Family Systems Theory Explained
Family systems theory, partially developed by psychiatrist Murray Bowen in the mid-20th century, views families as interdependent emotional units. Within this framework, one person's anxiety, anger, or depression doesn't exist in isolation - it reverberates throughout the entire group.
Emily Waitt, LMFT and founder of Kincove, a Los Angeles-based adolescent mental health center, explains that the designated patient "holds and acts out the stress of the family system." This person frequently gets labeled as the source of family problems, yet they represent a symptom rather than the cause of family dysfunction.
Research in family therapy consistently supports that symptoms emerging in one person often serve a regulatory function, preventing deeper conflicts or fears from surfacing within the group. Waitt notes that families typically assign this role unconsciously to externalize problems and avoid shame associated with their collective role in the family dynamic.
The Emotional Cost of Being the 'Problem'
For the individual cast as the designated patient, the experience proves profoundly isolating, with effects potentially lasting into adulthood. Dr. Nari Jeter, LMFT, describes how being the identified patient means bearing the family's problematic symptoms. Your struggles with eating disorders, substance abuse, acting out, depression, or anxiety become the reason the family seeks help.
Even well-intentioned attempts to help can reinforce shame, Jeter adds. Being labeled "the problem" by people we're supposed to love and trust further cements that role and self-perception.
Nilisha Williams, LPCC-S, founder of Ace Wellness, observes that people in this role often internalize blame and guilt, potentially developing low self-esteem, chronic shame, or difficulty forming healthy attachments. The pattern doesn't necessarily end when someone leaves home - some individuals recreate the scapegoat role in friendships, workplaces, or romantic relationships.
Moving Beyond the Blame Game
When families finally seek therapy, they often arrive with statements like "We need to fix her" or "He's the problem." While this might seem like progress, experts caution that therapy focusing solely on the identified patient risks reinforcing the same dynamic that created the problem initially.
Dr. Ditzell warns that singling out a designated patient can yield negative results, including unfair blame, shaming, or ultimate isolation from the family. Roma Williams, LMFT of Unload It Therapy echoes this concern, noting that the designated patient often gets pathologized and diagnosed - sometimes because insurance billing requires it.
This setup offers short-term relief but long-term harm, creating false stability because blaming others proves easier than confronting personal issues. The more one person gets labeled the trouble source, the less incentive the family has to examine its patterns of control, communication, and avoidance.
Pathways to Healing
The most effective family therapy approaches work to dismantle the "problem person" narrative and involve everyone in the healing process. According to Waitt, the first step involves shifting perspective from "this person is the problem" to "the family system is struggling." The goal moves focus from blame toward shared responsibility and healthier relational methods.
Family therapy research supports this approach, demonstrating that change becomes more sustainable when all members participate in exploring interaction patterns rather than focusing on "fixing" one individual. As Dr. Ditzell summarizes, the designated patient's symptoms represent "a shared reflection of the entire family system's health."
Williams explains her method: "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."
This systemic approach not only relieves the designated patient from carrying the family's emotional burden but creates opportunities for genuine, lasting healing across the entire family unit.
