This article discusses and illustrates with case examples the impact on the college experience for students who have impaired--medically or mentally ill, substance abusing, developmentally disabled--siblings. Although these students often show resilience and a well-developed sense of compassion, they may also struggle with developmental tasks of the college years. Compulsive altruism and conflicts about needing or receiving special attention influence normal developmental dilemmas of leaving home, forming new relationships, and vocational choice in characteristic ways. These challenges are elucidated and illustrated in this article with case examples. Implications for conducting psychotherapy, including transference and countertransference complications, are discussed. Understanding the difficulties of students with seriously impaired siblings may also alert clinicians to more subtle sibling issues in the broader student population. (Contains 1 note.)