One Team, One Direction: Why Eating-Disorder Recovery Requires Genuine Collaboration

When I began comparing Aotearoa New Zealand and Australian peer-workforce guidelines, I expected them to describe roughly the same way of working.

They did not.

Both value lived experience, hope, connection and recovery, but they do not necessarily position the lived-experience worker in the same way. The Aotearoa guidance leans strongly towards mutuality, autonomy and non-clinical relationships. The Australian eating-disorder guidance is more explicit about role boundaries, supervision, governance and integration within a multidisciplinary treatment team.

I also learnt something important that I suspect many clinicians may not fully appreciate: a recovery coach and a peer-support worker are not necessarily the same thing.

I had previously used the terms somewhat interchangeably. Having now looked more closely at the different guidelines, and at how recovery coaches are used within the American eating-disorder provider Equip Health, I can see that they may represent distinctly different practice models.

This distinction needs to be understood by clinicians, services, families and the people receiving support.

A coach and a peer-support worker may be doing different jobs

There is no universally consistent use of these titles. Some organisations call their workers mentors, some use peer workers, and others use recovery coaches. A role called “peer support” may contain coaching functions, while a recovery coach may use lived experience and peer-support principles.

We therefore cannot rely on the job title alone. We need to ask what the person is actually employed to do.

Broadly, the distinction may look like this:

Peer-support role	Treatment-integrated recovery-coaching role
Grounded in mutuality, connection and the intentional use of lived experience	Grounded in helping the person put an agreed treatment plan into action
Usually person-led, with goals emerging from the peer relationship	More structured and goal-directed, with goals connected to the wider care plan
Seeks to reduce hierarchy and create a relationship based on shared humanity	Has a defined practitioner role and responsibilities within a treatment service
May provide a space that is distinct from clinical treatment	Communicates and collaborates routinely with the clinical team
Information-sharing is negotiated according to consent, safety and the peer-service model	Sessions are often documented, with relevant information shared through team meetings or clinical records
Lived experience is the foundation and principal method of the work	Lived experience informs coaching, skills practice, encouragement and problem-solving
The worker is not automatically responsible for implementing clinical recommendations	The coach may actively help the person follow the agreed clinical plan, without independently changing it

Neither role is inherently better. They serve different purposes.

The problem arises when clinicians, patients and families believe they are receiving one kind of support when the service is actually providing the other.

A person may reasonably expect a peer-support relationship to offer a degree of independence from clinical treatment. A recovery coach embedded in a clinical programme, however, may be expected to document sessions, attend treatment-team meetings, monitor engagement and help the person follow the agreed plan.

That difference affects confidentiality, information-sharing, power, accountability and the person’s expectations of the relationship. It must be explained before the work begins.

Clinicians referring someone to a coach or peer worker should ask:

• What is the worker’s actual scope?

• Are they providing mutual peer support or treatment-integrated coaching?

• Are they expected to help implement the clinical plan?

• What information will they document?

• What will they share with the treatment team?

• What remains private?

• How are concerns and disagreements escalated?

• What training and supervision do they receive?

• Who remains accountable for medical, nutritional and psychological decisions?

Without those answers, neither clinicians nor patients can give genuinely informed consent to the arrangement.

The importance of one coordinated team

Looking at the American provider Equip Health revealed a highly treatment-integrated model. Equip embeds lived-experience recovery coaches and caregiver coaches within the same service as the dietitian, therapist and medical provider.

The coaches participate in the programme, document their work and help patients and families put the agreed treatment plan into practice. The dietitian remains responsible for nutritional rehabilitation, the medical provider oversees physical safety, and the therapist leads psychological treatment.

The value of this model is not simply that Equip employs people with lived experience. It is that each person has a defined function and everyone is expected to work together.

That matters enormously in eating-disorder treatment.

The eating disorder looks for gaps in the team

Eating disorders thrive in ambiguity. They look for differences between team members, uncertainty about treatment and opportunities to negotiate a less challenging path.

A person may tell the dietitian that the therapist agreed they could exercise. They may tell the therapist that the dietitian said the meal plan was flexible. A parent may hear one message while the young person hears another. A recovery coach may be told that the clinical team “doesn’t understand”, while clinicians are told that the coach agrees the treatment plan is too demanding.

This is often described as splitting.

Splitting does not necessarily mean that the person is being deliberately deceptive or manipulative. The person may be frightened, cognitively impaired by malnutrition, struggling with ambivalence or desperately seeking relief from the distress that treatment creates.

Sometimes the team itself creates the split through poor communication, unclear roles or genuinely conflicting recommendations.

However it arises, the result is the same: the team begins pulling in different directions, and the eating disorder gains room to operate.

We must be able to name this when it occurs.

That means saying, compassionately and directly:

“I notice that different members of the team appear to have received different versions of this conversation. Let’s bring everyone together so that we can understand what has happened and agree on one plan.”

We call out the pattern without shaming the person. We remain curious, but we do not pretend that inconsistent treatment messages are harmless.

The eating disorder loves the person who collaborates with it

This can be uncomfortable to say, but it needs to be said: the eating disorder will gravitate towards the person most willing to accommodate it.

That might be the professional who agrees that the meal plan is excessive, despite not being responsible for the nutrition prescription. It might be the coach who accepts that exercise is essential for mental health when the medical and dietetic team have said it is unsafe. It might be the clinician who repeatedly reduces expectations to avoid distress or protect the therapeutic relationship.

The eating disorder experiences this person as safe, not necessarily because the person is supporting recovery, but because they are protecting the illness from challenge.

Compassion is essential, but compassion without direction can become collusion.

This does not mean that every concern should be dismissed as “the eating disorder”. Treatment plans can be wrong. People may have genuine gastrointestinal symptoms, sensory needs, trauma responses, financial limitations, cultural food needs or medical complications.

Evidence-based treatment should never mean blindly following a protocol without listening.

The distinction is that concerns should be taken back to the person responsible for that area of care.

If a recovery coach hears that the meal plan feels unmanageable, their role is to listen, help the person identify the difficulty and communicate it to the dietitian. It is not to independently reduce the plan.

If a peer-support worker is operating independently from the treatment team, they should still understand the potential harm of giving nutrition, exercise or medical advice outside their competence.

If a coach or peer worker is worried that a treatment interaction has been harmful, they should raise the concern transparently through supervision or with the appropriate team member. They should not privately undermine the clinician while positioning themselves as the only person who truly understands.

Team members must be able to challenge one another. But those conversations should happen openly within the team, not through competing alliances with the patient.

Recovery coaches and peer workers need to understand transference and countertransference

Lived experience can create a uniquely powerful relationship. A recovery coach or peer worker may be the first person who makes someone feel genuinely understood. They can reduce shame, model hope and provide practical knowledge that cannot be learnt solely from textbooks.

But this closeness also creates risk.

Transference occurs when a person brings feelings, fears or expectations from previous relationships into a current relationship. A patient may experience their dietitian as controlling, their therapist as rejecting or their recovery coach as the protective older sister they always needed.

Countertransference refers to what is activated in the worker. A coach may recognise their younger self in the patient. They may feel compelled to rescue them from distress, defend them against their parents or prove that their approach to recovery was the right one. They may become angry with a clinician who reminds them of someone involved in their own treatment.

A worker might feel particularly valued when the patient says, “You’re the only one who understands me.”

That feeling is human, but it requires reflection. It can lead the worker to protect their special relationship by agreeing with the patient and distancing themselves from the rest of the team.

This is why goodwill and lived experience are not sufficient preparation for this work.

Recovery coaches and peer workers need training appropriate to their particular role, including:

• transference and countertransference;

• over-identification and rescue responses;

• appropriate self-disclosure;

• professional and relational boundaries;

• team communication;

• confidentiality and its limits;

• recognising deterioration and escalating risk;

• receiving feedback without experiencing it as rejection; and

• distinguishing the person’s needs from their own unfinished recovery experiences.

• 
  

They also need regular, skilled supervision.

Supervision is not merely a place to review administrative tasks. It should help the worker ask:

• What feelings does this person bring up in me?

• Am I trying to rescue, persuade, protect or control them?

• Am I avoiding something because it reminds me of my own treatment?

• Is my disclosure serving this person, or meeting a need in me?

• Am I supporting the person—or helping the eating disorder feel safer?

• 
  

Lived experience is a lens, not a treatment manual

A worker’s personal experience is valuable because it provides a perspective that clinical training cannot reproduce. But it remains one person’s experience.

What helped one person may be ineffective, inappropriate or unsafe for another. One person may have recovered without a meal plan, medication, family involvement or a particular weight-restoration approach. That does not establish what another person needs.

Statements such as “I never had to eat that much”, “My dietitian let me exercise” or “I recovered without gaining beyond this weight” can be particularly damaging. They may appear reassuring, but they give the eating disorder material with which to challenge the person’s individualised treatment.

Responsible lived-experience disclosure sounds more like:

“This was part of my experience, but your body, circumstances and treatment needs are different. Let’s work out what this means for you and, where appropriate, bring it back to your team.”

Before sharing, the worker should ask:

• Who is this disclosure for?

• What is its purpose?

• Will it increase hope and flexibility?

• Could it reinforce comparison, avoidance or eating-disorder rules?

Lived experience should open possibilities. It should not become another form of prescription.

Evidence guides us; lived experience informs us

Clinical evidence and lived experience should not be positioned as opposing forces.

Evidence helps us determine what is most likely to promote medical safety, nutritional rehabilitation, psychological recovery and reduced relapse risk. It guides decisions about monitoring, nutrition, treatment modalities and escalation.

Lived experience helps us understand what treatment feels like from the inside. It can show us where our language is alienating, where a plan is difficult to implement, why a person feels ashamed or misunderstood and what might make treatment more tolerable and meaningful.

Evidence should guide the direction of treatment. Lived experience should help shape how we travel in that direction.

This is visible in Equip Health’s team model. The dietitian directs nutritional rehabilitation, the medical provider oversees physical safety, and the therapist is responsible for psychological treatment. The recovery coach helps the patient translate that plan into everyday life, while the caregiver coach supports loved ones to implement treatment at home.

The coaches do not replace the clinical team. The clinical team does not treat coaches as decorative extras. Their knowledge is different, but complementary.

Preliminary research into Equip’s virtual five-person model has reported improvements in eating-disorder symptoms, weight restoration and caregiver confidence. However, this was observational research and does not establish how much of the improvement was attributable specifically to mentoring. It supports continued evaluation of integrated care rather than proving that one model will suit everyone. Published Equip study.

What genuine collaboration requires

A collaborative eating-disorder team needs more than goodwill. It requires structure.

Every team should have:

• one shared treatment plan;

• clearly defined responsibilities and scopes of practice;

• clarity about whether lived-experience support is peer support, treatment-integrated coaching or a combination of both;

• a named person coordinating clinical care;

• explicit consent about documentation and information-sharing;

• regular team communication;

• timely, factual documentation where this forms part of the role;

• agreed language and treatment goals;

• a process for resolving professional disagreement;

• supervision for both clinical and lived-experience workers; and

• clear medical, psychiatric and safeguarding escalation pathways.

  
  

The patient should not have to carry messages between providers. Nor should they be placed in the position of deciding which professional is correct when the team gives conflicting advice.

Most importantly, every team member must be able to articulate the shared destination.

The goal is not simply engagement. It is not indefinite support, avoidance of distress or maintenance of a comfortable therapeutic relationship.

The goal is recovery: adequate and flexible eating, improved physical and cognitive functioning, freedom from eating-disorder behaviours and the ability to build a life that is no longer organised around the illness.

There will be times when treatment causes distress. There will be disagreement, ambivalence and fear. A good team does not interpret this as failure, nor does it abandon compassion. It listens carefully, adapts where appropriate and remains united in moving towards recovery.

Both peer support and recovery coaching can make important contributions to eating-disorder care. But they are not automatically the same service, and we should stop using the terms as though they are interchangeable.

Clinicians need to understand the distinction. Workers need to be clear about which role they are providing. Patients and families deserve to know what kind of relationship they are entering, what will be shared and how the worker connects with the wider treatment team.

No team member, clinical, coaching or peer, should operate as an island, and no relationship should become a protected place where the eating disorder goes unchallenged.

We must work together closely enough to recognise splitting, safely enough to discuss countertransference and humbly enough to remember that none of us holds the whole picture.

Evidence guides us. Lived experience informs us. Recovery is the shared destination.