Tricia was depressed. That was her only problem. Although her life had all the right ingredients—successful husband, decent job, close-knit family—Tricia felt so low that she sometimes threatened suicide. When her therapist invited her husband, parents, and sister for a family session, a discussion of Tricia's "spells" devolved into a verbal brawl. Her parents, who'd been drinking, bickered about their mutual infidelity. Her sister wept like a fire hydrant. Tricia's husband shouted that they were ruining his life. In short, Tricia's depression was not her only problem. Instead, it was what I call her designated issue.

Tricia herself would be recognized by systems therapists as a "designated patient," the one person in a family or group who's singled out as sick or abnormal, allowing everyone else to feel healthy by comparison. A designated patient "carries" the group's dysfunction. A designated issue performs the same service for an individual, dominating our psyches so that other troubles can go unnoticed.

You probably have a designated issue. Almost all my clients do. (And I myself have had several.) Annabeth obsesses endlessly about her weight (once upon a time, I did, too). Libbie pines for a soul mate (been there, done that). Loving mother Kristen worries constantly about her children's safety (I'm three for three). As a designated-issue connoisseur, I know what these ladies think: If they could only fix this problem, life would be a bowl of pitted Maraschino cherries. But their problems stubbornly resist fixing. Why? Because designated issues aren't just problems; they're also solutions. Like toxic-waste receptacles, they serve the useful function of containing some nasty, scary material. Your so-called worst problem may be sparing you even greater distress. You can thank it for that. And then you can get rid of it—though not quite in the way you might expect.

Life, as psychologist William James famously said, is "one great blooming, buzzing confusion." We stumble through it, suffering many woes and imagining infinite others, with all the confident self-assurance of squirrels trying to teach dog obedience classes. To calm ourselves, we may pickle our fears in alcohol, scorch them with nicotine, haul them to yoga, therapy, and church. Focusing on one mildly disturbing, semi-controllable issue allows the mind to stuff much greater terrors in relatively tidy packages. Yes, Earth's climate is changing, bird flu seems imminent, wars and genocides rage—and wouldn't you rather think about your cholesterol level?

Me, too.

This is the real reason Tricia developed the moody blues. Her depression let everyone in her family worry just enough to avoid facing 50-some years of truly spectacular dysfunction. When Tricia's therapist threw a wrench into this system, his designated patient's designated issue coughed up secrets everyone had been hiding. Here are some more true stories:

"I'm sick of thinking about my weight," moaned chubby Annabeth.

"Okay," I replied, "let's talk about your marriage."

"Sure. Just a second," said Annabeth. She yanked a king-size candy bar from her purse and attacked it like a starving lumberjack—something she did whenever the topic of marriage arose.

Like Annabeth's weight problems, Libbie's quest for the perfect relationship was a 24/7 occupation. I thought it might be useful to discuss her avocation of selling marijuana, but getting her off the topic of romance was like taking beefsteak from a pit bull. If she'd been any less stoned, I might've lost a finger.

Kristen's crisis hit when she bounced a check to the private investigator she'd hired to make sure her grown children were living safely while at college. The kids were fine, but Kristen's finances were in shambles—a problem she'd pushed aside to focus on protecting her young.


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