Why Siblings Matter in Family-Based Treatment (FBT) for Eating Disorders: Understanding Their Essential Role in Recovery
Why Are Siblings Included in Family-Based Treatment (FBT)?
When a child develops an eating disorder, the entire family is affected—not just parents. Brothers and sisters often experience confusion, fear, frustration, guilt, and significant changes to everyday family life. For this reason, Family-Based Treatment (FBT), also known as the Maudsley Method, intentionally includes siblings whenever appropriate.
Many families wonder:
"Why does my healthy child need to attend therapy?"
"Will involving siblings make things worse?"
"Shouldn't we protect them from all of this?"
These are understandable questions.
Research consistently demonstrates that eating disorders are family illnesses—not because families cause them, but because they impact every member of the household (Lock & Le Grange, 2015). Involving siblings thoughtfully can improve family communication, reduce fear and misunderstanding, strengthen recovery, and ensure that siblings themselves receive the support they deserve.
At Ezer Psychotherapy, we believe siblings should never become forgotten members of the recovery team.
Family-Based Treatment Is About Using the Family as the Primary Resource
One of the biggest misconceptions about FBT is that everyone in the family is responsible for treating the eating disorder.
That isn't true.
Parents carry the responsibility for restoring nutrition and interrupting eating disorder behaviors.
Siblings have a very different role.
Rather than becoming mini-therapists or extra parents, siblings help preserve normal family relationships and remind the child that life exists outside the eating disorder.
In traditional FBT:
Parents lead meals.
Parents supervise recovery.
Parents make treatment decisions.
Siblings continue being siblings.
This distinction is extremely important because it prevents siblings from becoming responsible for recovery while still allowing them to contribute in meaningful ways (Lock & Le Grange, 2015).
Eating Disorders Affect Every Member of the Family
Research has repeatedly found that siblings often experience significant emotional consequences when a brother or sister develops an eating disorder.
Common experiences include:
Anxiety
Feeling overlooked
Jealousy about parental attention
Fear that their sibling might die
Confusion about eating disorder behaviors
Anger toward the illness
Guilt for being healthy
Increased household stress
Many siblings also quietly assume caregiving roles without adults realizing it.
A comprehensive review of the literature found that siblings frequently experience disruptions in emotional well-being, family relationships, school functioning, and social life while coping with a loved one's eating disorder. Unfortunately, siblings have historically received far less clinical attention than parents or the identified patient.
What Siblings Learn During FBT
One goal of sibling involvement is education.
Children often fill in gaps in understanding with inaccurate conclusions.
Without education, siblings may believe:
"She's choosing not to eat."
"He's just trying to get attention."
"If I were nicer, this wouldn't be happening."
"Maybe I caused it."
"If she would just eat, everything would go back to normal."
FBT helps replace these misconceptions with accurate information.
Siblings learn:
Eating disorders are serious brain-based illnesses.
Their sibling is not choosing the illness.
Parents are temporarily taking charge because the illness affects judgment.
Recovery takes time.
They are not responsible for fixing the eating disorder.
This understanding often reduces fear while improving empathy.
Siblings Help Externalize the Eating Disorder
A hallmark of FBT is externalization.
Rather than viewing the child as "being difficult," families learn to separate the eating disorder from the person.
Instead of saying:
"You're refusing dinner."
Families learn to think:
"The eating disorder is making dinner difficult today."
Siblings naturally become part of this language.
They begin recognizing:
"That's the eating disorder talking."
"My sister isn't choosing this."
"My brother isn't trying to hurt us."
This shift decreases blame while protecting sibling relationships.
Siblings Help Preserve Normal Childhood
One of the greatest risks during eating disorder treatment is allowing the illness to consume the family's entire identity.
When every conversation centers on:
calories
weight
meals
appointments
medical monitoring
children can begin to feel that recovery is the family's only purpose.
Healthy siblings often provide something invaluable:
normalcy.
They continue to:
play games
watch movies
tease each other
celebrate birthdays
laugh together
share hobbies
These ordinary moments remind everyone that the eating disorder does not define the family.
Siblings Are Not Junior Parents
Perhaps the most important principle in FBT is this:
Siblings should never become responsible for treatment.
That means siblings should not:
monitor meals
supervise eating
weigh their sibling
argue about food
enforce consequences
report every eating disorder behavior
Those responsibilities belong to parents.
When siblings become caregivers, relationships often become strained.
Instead, siblings should remain emotional supports and continue having age-appropriate relationships.
Research examining sibling experiences in FBT found that siblings valued participating in treatment but did not want responsibility for managing the illness. They wanted to understand what was happening while maintaining their role as siblings—not parents.
What Does a Sibling Actually Do During FBT?
Every family is different.
Some siblings attend every session.
Others attend periodically.
Typical sibling roles include:
Providing Encouragement
Simple statements matter:
"I'm glad you're here."
"Let's watch a movie after dinner."
"Want to play cards?"
These reinforce connection without focusing on food.
Helping Family Life Stay Normal
Maintaining routines reduces the feeling that the illness controls the household.
Participating in Family Meals
Eating together models healthy behavior and reduces isolation.
Asking Questions
Therapy sessions provide a safe place for siblings to ask:
"Can she die from this?"
"Why is she angry all the time?"
"Why can't she just eat?"
Open conversations reduce fear and misunderstanding.
Parents Must Continue Protecting Healthy Siblings
One common concern among parents is:
"I'm spending all my time helping one child. What about my other children?"
This concern is valid.
Parents should intentionally protect sibling well-being by:
scheduling one-on-one time
attending their activities
asking about school
maintaining family traditions
celebrating accomplishments
checking in emotionally
Healthy siblings need reassurance that they remain important.
When Siblings Need Their Own Support
Sometimes siblings need more than occasional participation in FBT.
Warning signs include:
withdrawal
increased anxiety
depression
declining grades
perfectionism
obsessive exercise
restrictive eating
binge eating
body dissatisfaction
Some siblings develop eating disorder symptoms themselves, particularly if they have genetic vulnerability combined with environmental stressors.
Early intervention is essential.
Siblings deserve their own support—not because they caused the illness, but because living alongside an eating disorder can be incredibly stressful.
Do Siblings Need to Attend Every Therapy Session?
Not necessarily.
FBT is individualized.
Some families benefit from:
siblings attending every session
attending monthly
joining Phase One only
participating during specific discussions
Research suggests that sibling attendance should be thoughtful rather than automatic. Families benefit most when expectations are discussed openly and sibling involvement is purposeful rather than symbolic.
What Recent Research Tells Us
Although FBT manuals recommend sibling involvement, newer research has found that siblings are often under-involved in actual clinical practice.
A 2025 mixed-methods study reviewing pediatric eating disorder care found that only a small minority of siblings attended treatment sessions and that documentation of sibling support was limited despite guideline recommendations. Researchers concluded that services should develop broader approaches to supporting siblings rather than viewing involvement solely as session attendance.
This highlights an important opportunity for clinicians and families alike: involving siblings intentionally, educating them, and ensuring they also receive emotional support.
Practical Tips for Parents
Here are several ways parents can support siblings during FBT:
Explain the eating disorder using age-appropriate language.
Encourage questions without judgment.
Avoid asking siblings to police meals.
Continue family activities unrelated to recovery.
Schedule individual time with each child.
Watch for emotional or behavioral changes.
Celebrate recovery milestones together.
Let siblings express frustration without guilt.
Consider individual therapy if needed.
Frequently Asked Questions
Can siblings make recovery worse?
Not when appropriately involved. Healthy sibling participation typically strengthens family understanding and reduces isolation. Problems arise when siblings are expected to monitor or manage treatment.
What if siblings don't want to attend therapy?
This is common. Therapists can explore concerns and determine whether occasional participation or separate sibling sessions may be more appropriate.
Can siblings trigger eating disorder behaviors?
Sometimes siblings unintentionally make comments about food, weight, exercise, or appearance that reinforce eating disorder thinking. Psychoeducation helps families recognize and reduce these risks.
Should siblings know the diagnosis?
Generally, yes—using developmentally appropriate language. Honest communication tends to reduce fear, confusion, and misinformation.
Recovery Is a Family Journey
Family-Based Treatment recognizes an important truth:
Recovery happens within relationships.
Parents provide leadership.
Clinicians provide guidance.
Medical providers monitor health.
Dietitians support nutrition.
And siblings provide something no professional can replace:
They offer companionship, hope, laughter, and the reminder that life is bigger than an eating disorder.
When siblings are informed, supported, and allowed to remain simply brothers and sisters—not caregivers—they become powerful allies in long-term recovery.
At Ezer Psychotherapy, we work with the entire family to help every member feel heard, supported, and empowered throughout the recovery journey.
References
Hughes, E. K., Sawyer, S. M., Accurso, E. C., Singh, S., Le Grange, D., & others. (2018). “They don't really get heard”: A qualitative study of sibling involvement across two forms of family-based treatment for adolescent anorexia nervosa. Eating Disorders, 26(4), 348–365.
Hughes, E. K., Le Grange, D., Court, A., Sawyer, S. M., & others. (2017). The participation of mothers, fathers, and siblings in Family-Based Treatment for adolescent anorexia nervosa. Journal of Clinical Child & Adolescent Psychology, 47(S1), S456–S466.
Lock, J., & Le Grange, D. (2015). Family-Based Treatment of Child and Adolescent Eating Disorders. Child and Adolescent Psychiatric Clinics of North America, 24(3), 617–629.
Lock, J., & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach (2nd ed.). Guilford Press.
Maon, I., Horesh, D., & Gvion, Y. (2020). Siblings of Individuals With Eating Disorders: A Review of the Literature. Frontiers in Psychiatry, 11, 604.
Treasure, J., & Murphy, T. (2010). When Helping Hurts: The Role of the Family and Significant Others in the Treatment of Eating Disorders. In Treatment of Eating Disorders: Bridging the Research-Practice Gap.
Westmoreland, P., et al. (2025). Sibling Involvement and Documentation in Pediatric Eating Disorder Care. International Journal of Eating Disorders.
