Family Therapy Has Always Evolved – Now Includes Sibling Therapy


I had the good fortune of having discovered the field of family therapy before there were separate schools. I was living in Boston in the late ‘60s and early ‘70s. Some of the noted early pioneers would travel around the country offering one-day trainings. They each had their own special orientation. Some just did a training while others interviewed families while we observed in the same room (this was before one-way screens).

It was a very exciting time. I participated in trainings by Carl Whitaker (Whitaker & Keith, 1981) and his symbolic-experiential approach; Ivan Boszormenyi-Nagy (Boszormenyi-Nagy & Spark, 1973), best known then for his emphasis on invisible loyalties within families; Murray Bowen (1967) with his emphasis on differentiation of family members across generations. Sal Minuchin (1974) joined the Philadelphia Child Guidance Clinic, emphasizing the structure and process of family interactions. And, Jay Haley (1963), who had been with the Palo Alto group, joined Minuchin with his own concepts of conceptualized double bind paradoxical communications.

You’ll notice these are all men. The first woman who traveled around in these early years teaching her concept of working with families was Virginia Satir (1967). She demonstrated “Sculpting” as a non-verbal means of communicating among family members.

Though not an attempt to summarize their concepts, this is what I remember about them as the field of family therapy evolved. There were so many more wonderful trainers, but these are the very first ones whose ideas eventually grew into different “schools” of family therapy.

Since then, the field has continued to evolve with many new approaches, yet one thing has remained consistent—MFTs think from a systemic approach.

The emphasis had always been on the family as a whole—the couple’s relationship, the parent-child relationship. Even the “family” evolved, as in Narrative Therapy (White & Epston,1990) which views people as separate from their problems, and the internal family system of an individual (Schwartz, 1997).

As my own family therapy practice evolved over this half a century, I first fell into working with young siblings in foster care (Lewis, 1983, 1984, 1986). Then, as I was working in an eating disorder program, I began noticing that women’s bulimia often had a (unconscious) message to a sibling (Lewis, 1988).

From there, I began to see how childhood sibling relationships were affecting my individual, couples, and family clients. By asking how they got along with their siblings in pre-school years, I saw these feelings, positive and negative, transferred onto their love and friendship relationships. Surprisingly, their ability to be successful (or self-sabotage) at work was also affected. Thus, still thinking systemically, I’ve come to call siblings a “hidden resource” (Lewis, 1990), regardless of how many people are in my office.

To demonstrate that, here are three entirely different client problems—an individual woman, a married lesbian couple, and a family with adult children.

Carol was an attorney in commercial real estate for 15 years. She told me, “I’m a great attorney for most buyers. But, when the high-powered big buyers come in, I let them push me around. Why? This doesn’t make any sense.”

Malika and Ebony had been married for 10 years and had two children. They were both successful professionally and clearly committed to their marriage. But, to hear them tell it, it was an awful marriage; they argued constantly.

Mr. and Mrs. Zeno and their two adult daughters came to therapy because the older daughter’s depression had become an all-consuming family project.

It turns out that each of these problems is related to unresolved issues from childhood— with their siblings, as I’ll explain later.

What became clear to me over time were four concepts underlying each of these, and many other families: frozen images, crystallized roles, unhealthy loyalty, and sibling transference.

  1. Frozen Images: How one felt about a sibling in early childhood can become frozen and reflect how one sees them today, despite how much each has changed. These images from childhood can be positive or negative and become “frozen” for years to come.
  2. Crystalized Roles: Parents tend to assign roles to their children—such as the comic, the smart one, the troublemaker, the irresponsible one. In adulthood, the role may no longer fit, yet it may have become crystallized to how family members still see them, and how they see themselves.
  3. Unhealthy Loyalty: This concept is subtle. While family loyalty can be healthy, it can get interpreted (unconsciously) to mean accepting one’s crystallized role. That is, being loyal to old roles and frozen images may contribute to self-sabotage, affecting success in relationships and at work.
  4. Sibling Transference: Siblings may bring their frozen images and crystalized roles from early childhood into their current love and work life, responding as they had to their young siblings. This may result from unhealthy loyalty.

I call these four concepts “ghosts”; what makes this so complex is that, like ghosts, these behaviors are unconscious (i.e., invisible) and inconsistent, making it hard to identify when it is happening.

Going back to the three examples above, Carol was stuck in a negative frozen image of her mean/powerful older brother. Malika and Ebony had recreated a sibling transference from each of their older siblings. And, the Zenos discovered they each had a three-generation history of a young sibling being the caretaker of a troubled or incapacitated brother or sister—which they (and their younger daughter) were perpetuating with their depressed daughter.

So, how do we, as MFTs, ferret out if there is a sibling issue with our clients?

Some of the types of clinical situations that prompt my looking for lingering ghosts or a sibling transference include when a client:

  • is stuck in an unhealthy role in one or more relationships or has a pattern of unhealthy relationships
  • is bright and successful but underachieving or self-sabotaging at work
  • feels guilty about taking steps to improve life that would be helpful.

True, there are many possible explanations for these situations. So, I hypothesize the possibility of a sibling connection and then ask questions to rule it in or out. I start by asking if they have siblings. If the answer is no, clearly, I move on.

If the answer is yes, I ask questions about possible similarities or contrasts between their problem and their siblings, such as:

  • What would your sibling do in this situation?
  • How is your sibling’s marriage?
  • Think back to when you were in elementary school and any qualities in your siblings you didn’t like. Does your spouse or co-worker have similar ones?
  • Who among your siblings makes the most money or has the most prestigious job? Who the least?

It may be, through the discussion, you find no connection. Or, you begin to suspect one of the “ghosts.” It’s one thing, though, for us to suspect a connection; more important, though, is to help the client see it.

If asking these questions does not lead the client to see any similarity, I may say something like, “You’ve just been telling me that your boss doesn’t like you, and in talking about your sister, you say she never liked you. Is there a possible connection?” Or, “I notice you’ve used the same words in describing your brother that you have been in describing your husband. Are you curious about that?”

This is how I started—seeing sibling connections to my current clients. Often my client or I would suggest meeting with the brothers and/or sisters together. Then, a few years ago, I began getting referrals specifically for sibling therapy. I’m not exaggerating when I say I frequently get three such requests daily.

The field of family therapy has greatly expanded since the 1960s (far more than I’ve mentioned here), all to the benefit of helping our clients. While most MFT training programs teach the different schools of family therapy, they all are based on the core principle—systemic thinking. These four concepts of sibling therapy can easily be incorporated into training programs and whatever therapeutic approach you currently use with your clients.

What became clear to me over time were four concepts underlying each of these, and many other families: frozen images, crystallized roles, unhealthy loyalty, and sibling transference.

Karen Gail Lewis, MSW, EdD, is an AAMFT Professional member holding the Clinical Fellow designation and has been a member for 50 years. She has authored numerous books and professional articles on marriage, gender communication, single women, group therapy, and adult siblings. Her newest book is Sibling Therapy: The Ghosts from Childhood That Haunt Your Clients’ Love and Work (2023, Oxford University Press). She has been active in AAMFT locally and nationally, presenting her work nationally and internationally. She has several presentations coming up on “Siblings Therapy as a Hidden Resource,” and “Sibling Therapy: The How Tos.”;

Boszormenyi-Nagy, I., & Spark, G. (1973). Invisible loyalties. Harper & Row.

Bowen, M. (1967). Toward the differentiation of self in one’s own family. In J. L. Framo (Ed.), Family interaction: A dialogue between family researchers and family therapists (pp. 111-173). Springer-Verlag.

Haley, J. (1963). Strategies of psychotherapy. New York: Grune & Stratton.

Lewis, K. G. (1983, September). Sibling therapy, part I. Family Therapy News.

Lewis, K. G. (1984, October). Sibling therapy, part II. Family Therapy News.

Lewis, K. G. (1986). Sibling therapy with children in foster homes. In L. Combrinck-Graham (Ed.), Treating young children in family therapy, Rockville, MD: Aspen.

Lewis, K. G. (1988). Symptoms as sibling messages. In M. Kahn and K. G. Lewis (Eds.), Siblings in therapy: Life span and clinical issues. W. W. Norton.

Lewis, K. G. (1990). Siblings: A hidden resource. Journal of Strategic and Systemic Therapies, 9, 1, 39-49.

Minuchin, S. (1974). Families and family therapy. Harvard University Press.

Satir, V. (1967). Conjoint family therapy. Science and Behavior Books.

Schwartz, R. (1997). Internal family systems therapy. Guildford Press.

Whitaker, C. A., & Keith, D. V. (1981). Symbolic-experiential family therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (pp.187-225). New York: Brunner/Mazel.

White, M. & Epston, D. (1990). Narrative means to therapeutic ends. W. W. Norton & Company.

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