TIFT #28 Almost as Damaging as Trauma: The Sick Sibling Syndrome

This is a post I have wanted to write for some time. It is not new, but a reminder of the power of the conscience. A significant portion of cases in my practice arise from what has been called the “sick sibling syndrome,” where the well child internalizes the value of caring, not only for the sick sibling, but, perhaps more important, the value of sparing the parents from demands for attention while excusing their preoccupation with the sick one. The result is that basic needs of the healthy child are chronically neglected with an inner prohibition against complaining or even acknowledging the shortfall. In contrast, when abuse and neglect are overt, it is relatively easier for the child to recognize the wrongness and to seek out others to have needs met. With blockage, both for fulfillment and for expression of discontent, neglect of personal needs can and often does extend for a lifetime.

The key to this problem is the conscience. As noted in TIFT #19, the conscience begins to develop neurologically around 18 months and becomes available at about 3 years. That is when children begin to aspire to be “good.” From the point of view of evolution it is clearly advantageous to the individual to take good care of the mental health of overstressed parents. When parents are ill themselves or preoccupied with the illness of a family member, children quickly recognize the situation and internalize the need to suppress their own demands so as not to overburden the parent. The pattern holds not only for sick siblings, but for a spouse who is ill or addicted, or even a grandparent or other relative.

As I have pointed out before, emotional needs, in our socially oriented species, are a life and death matter. It is normal and deeply embedded in human development that children do whatever is necessary to assure that their emotional needs are met. This imperative operates in different ways at different stages of development. Very small babies react vehemently to an unresponsive face. It is not until the conscience begins to function that the sick sibling syndrome can arise. The newly acquired ability to self-inhibit raises the possibility of supporting the parents against the child’s own needs. This is not just theoretical, but is a powerful force in itself. An impossible conflict is created between the need to support the parents and the individual needs of the child. Consistent with ultimate survival, the wellbeing of the parent typically takes precedence over immediate needs. It is further characteristic of the conscience that, once a value is internalized, it has tremendous lasting power, and, as pointed out in the earlier post, is probably permanent unless overridden by a new value.

Even in the case of a sibling who acts out voluntarily or a parent who is addicted, the child somehow recognizes and forgives the disabled one, while focusing on the wellbeing of the parent who may eventually be able to fulfill the child’s own emotional needs. Anger is rare at the one who causes the trouble, while it is firmly suppressed in relation to the one who could give, but is preoccupied.

Where do the needs go?

One common place for needs to be expressed is in physical self-soothing. Seeking physical comfort can lead eventually to addictions, sexual problems, eating disorders, self harm, and other compulsive behaviors. The other side of the same coin is damage to the ability to seek interpersonal warmth and support. Shame is the punishment for violating the internalized prohibition against putting pressure on the parent. This powerful deterrent creates an effective and lasting block against accepting comfort from other sources as well. 

In later important relationships, emotional self-sufficiency creates the equivalent of an avoidant attachment style. The person suffering from this syndrome may appear altruistic, but the inability to take creates an imbalance in any long-term relationship. The blockage in the ability to receive is particularly frustrating for a partner who expects a healthy balance between give and take.

Treatment: The importance of intellectual conviction

As noted in TIFT #9, dealing with the conscience, the way to change maladaptive values, such as one that dictates excessive altruism, is to install or re-awaken the antidote, a value that is positive for equal give and take. The process is not easy, but starts with education, necessary because the old value will be defended by rationalizations. “It would be so selfish to make demands on others.” Intellectual clarity, in simple verbal terms, can have lasting power to provide a counter-argument. 

“Civil Disobedience” is crucial

The next, essential element for change is “civil disobedience,” that is, doing the opposite of what the old value dictates along with being willing to tolerate the resulting shame, meted out by the conscience. In this case, the new, balanced behavior is nuanced and particularly hard to grasp for the procedural mind. Giving is still valued but must be equalled by taking. The unconscious mind has trouble with anything but absolutes, so it must form a new concept to cover the idea of equal give and take, now seen as distinct from, even opposite to, exclusively giving.

Due to the strong action of the conscience to maintain behavior within what it considers to be the “norm,” the patient can expect to feel quite strange, if not downright uncomfortable, about adopting a new pattern of behavior. Eventually a new norm can be established, with the ever-present possibility of relapse under unusual conditions. Ongoing help from others is an important support for this long-term change process.

Loss of substitutes for emotional needs

When substitute behaviors have taken the place of human sources for emotional needs, then taking away those gratifications, that is, eating disorders, etc., will be difficult unless relationship sources have been cultivated. To an extent, this may happen spontaneously, but it is far better to buttress the process with conscious attention to emotional support derived from relationships.

A common non-psychotherapy example

A good example is Alcoholics Anonymous. Here, the alcoholic is urged to become totally abstinent. However, concomitant with achievement of abstinence, the AA program emphasizes the provision of intense support. The newly abstinent person is urged to choose a “temporary sponsor” and to go to “90 meetings in 90 days.” As long as the individual has some residual capacity to receive emotional support, receiving personal attention is built in. Thus, the AA program provides a complete solution to the problem of switching from non-human to human sources of emotional support as in the sick sibling syndrome or some other situation where there has been a shortfall in emotional needs.

Conclusion

The altruism (driven by important personal needs), of children is remarkably powerful. It extends into adulthood and can be damaging to relationships and highly resistant to change. The challenge of long term recovery is on a par with that of overt trauma and, because the pathological side of self-sacrifice is often not obvious, it may go unnoticed or seen as a personality trait.

Jeffery Smith MD

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