Lived experience perspectives of receiving peer support in eating disorders

Abstract

Background

Peer support (PS) is increasingly incorporated into eating disorder services as an adjunct to clinical treatment, yet qualitative evidence exploring how it is experienced by service users remains limited. Since 2023, the Eating Disorders Unit at South London and Maudsley (SLaM) NHS Foundation Trust has piloted a 1–1 PS pathway alongside routine care.

Methods

Semi-structured qualitative interviews were conducted with twelve adults diagnosed with an eating disorder who had received 1–1 PS within outpatient or day care services. Interviews explored participants’ subjective experiences and the perceived meaning of PS within their wider recovery journeys. Data was analysed using reflexive thematic analysis within a constructivist–interpretivist framework.

Results

Seven interrelated themes captured how participants experienced PS: relational understanding and normalisation; informality and shared power; re-positioning the eating disorder within a wider life; safety and non-judgement; imagining recovery through lived example; practical knowledge as relationally embedded; and multi-layered relatability. Participants described PS as distinct from formal treatment, valuing its relational qualities and lived-experience grounding. A commonly reported limitation concerned the time-limited nature of PS, with many participants expressing a desire for additional sessions.

Conclusions

This qualitative evaluation provides insight into how 1–1 PS is experienced within a specialist eating disorder service. Rather than evidencing effectiveness, the findings illuminate relational and meaning-making processes through which PS was perceived as helpful. These insights informed the development of an eating disorder–specific PS feedback tool and have implications for service development and future research.

Plain language summary

Eating disorders are serious mental health difficulties that can affect both physical health and everyday life. Although psychological treatments can be helpful, many people find recovery difficult and services are often under pressure. Peer support involves receiving support from someone who has their own lived experience of an eating disorder and recovery.

Since 2023, the Eating Disorders Unit at South London and Maudsley NHS Foundation Trust has offered 1–1 peer support alongside usual eating disorder treatments. This study explored how people experienced this support. Twelve adults who had received peer support were interviewed.

Participants described feeling understood, less judged, and more able to open up. Seeing a peer support worker who had experienced recovery helped participants feel hopeful and imagine a future beyond their eating disorder. Peer support also helped some people reconnect with valued parts of life, such as hobbies, relationships, and goals.

Some participants described an initial apprehension around potentially triggering aspects of the PS roles, prior to starting the sessions.

A common challenge was that peer support was time-limited, and many participants wanted additional PS sessions.

These findings informed the development of a new feedback questionnaire which aims to capture what service users find most meaningful about peer support.

Introduction

Eating disorders are severe psychiatric conditions characterised by persistent disturbances and differences in eating behaviours—such as restrictive dieting, binge eating, and/or compensatory behaviours—as well as pervasive and intense concerns about body weight, shape, and self-perception [1]. These disorders have a considerable lifetime prevalence—8.4% in women and 2.2% in men—and are associated with elevated morbidity and mortality rates [2]. Anorexia nervosa has the highest mortality rate of any psychiatric illness [3, 4].

The impacts of eating disorders are multidimensional and include physical health complications, significant psychological distress, impaired functioning and social difficulties. Treatment guidelines emphasise the need for early and sustained intervention. However, outcomes remain suboptimal across diagnoses, and in recent years, this treatment gap has continued to widen. The COVID-19 pandemic further exacerbated the prevalence and severity of eating disorders globally, placing additional strain on already overstretched services [5–7].

Current psychological interventions, although evidence-based, demonstrate limited efficacy for many clients. For example, in adults with anorexia nervosa there is no clear superiority among first-line treatments, and treatment outcomes remain modest. Byrne [8] reported that only 50% of clients achieved a healthy weight post-treatment, and only 28.3% met the criteria for remission at 12 months. Family-based treatment, the leading intervention for adolescents, has shown mixed results, with remission rates ranging between 22.2% and 42% at follow-up [9, 10]. Other eating disorders also have modest recovery rates, with symptom abstinence rates of 35.4% for bulimia nervosa and 50.9% for binge eating disorder [11, 12].

Given the growing complexity of presentations and limited efficacy of existing treatments, there is an urgent need to enhance conventional care through adjunctive, recovery-oriented approaches that address motivation, identity, and lived experience. Peer support (PS) is one such approach that is gaining increasing traction in mental health care.

PS involves individuals with lived experiences of mental illness and recovery, providing support to others experiencing similar challenges. Grounded in principles of mutuality, empathy, and empowerment, PS has become a key pillar of recovery-oriented care across many mental health systems [13]. Peer support workers (PSW) offer not only emotional and practical support but also a sense of hope rooted in their own personal recovery journeys. Their role in shaping policy, practice, and research has been recognised as essential for creating equitable and collaborative services [14]. Mead [15] defined PSW as “offering and receiving help, based on shared understanding, respect, and mutual empowerment between people in similar situations.”

PS can take many forms—1–1 or group-based, in-person or remote, and often complements other treatment modalities. This flexibility has supported its integration across diverse mental health settings, although the heterogeneity of delivery models presents challenges for evaluation.

A systematic review revealed that, while 1–1 PS did not consistently improve clinical symptoms, it was associated with greater self-reported empowerment, recovery, and social connection [16]. The authors highlighted the low-to-moderate quality of studies and called for more rigorous evaluations.

Digital PS models have expanded rapidly, particularly in response to the pandemic. A review of 30 studies on digital PS reported positive acceptability and initial outcomes, although effectiveness varied and attrition was often high [17]. Despite mixed findings, PS remains a promising component of person-centred mental health care, especially for populations underserved by traditional interventions.

The integration of PS into eating disorder services is a relatively recent development, with programs varying considerably in structure, intensity, and therapeutic focus. Some are highly flexible and user-led, with content co-developed by mentors and mentees [18], whereas others are semi-structured or based on specific recovery frameworks [19, 20]. PS has been implemented across multiple settings, including outpatient, inpatient, and digital platforms [21, 22].

Within these contexts, PS may address motivation for recovery, emotional regulation, trigger identification, and relapse prevention [23]. There is also a growing interest in PS for carers and families, with emerging evidence supporting its utility in enhancing understanding and reducing the impact on carers [24, 25].

Empirical studies have identified several potential benefits for individuals with eating disorders receiving PS. Reported outcomes include reductions in eating disorder symptoms and mood disturbances [20], improved quality of life [23, 26], enhanced motivation and hopefulness [27], and reduced feelings of isolation [28]. PS has also been associated with increased emotional functioning [26], re-engagement with broader life domains [21], and reinforcement of adaptive coping strategies [29].

However, the evidence is not unequivocal. Some trials have failed to show sustained benefits, with effects dissipating at follow-up [30, 31]. Others have reported no significant differences between PS and control conditions [18–20]. These mixed findings, combined with methodological variability, underscore the need for additional high-quality studies and deeper exploration of client perspectives through qualitative methods.

PS is now a formal component of UK mental health policy. The NHS Long-Term Plan and the Mental Health Implementation Plan set targets to expand the PS workforce, aiming to recruit 4730 PSWs by 2024 [32, 33]. In support of this initiative, the National Collaborating Centre for Mental Health developed a national competency framework outlining key capabilities for effective PS delivery [34].

Within eating disorder care specifically, both the NCCMH [35] and the Scottish government [36] have recommended embedding PS to improve client engagement and recovery outcomes.

In line with these priorities, the Eating Disorders Unit at South London and Maudsley NHS Foundation Trust launched a dedicated PS pathway (Fig. 1) in April 2023. This initiative offers multiple formats of PS across outpatient and day care departments and has supported over 200 clients to date via group and 1:1 interventions.

Fig. 1 The peer support pathway. This figure displays a visual map of the peer support pathway (PS pathway), whereby trained peer support workers draw on personal lived experience of recovery to provide non-clinical, recovery-oriented support, alongside standard multidisciplinary care

The PS pathway was co-produced by individuals with lived experience and blended existing NHS structures (e.g. a referral + allocations process, offering time-limited support) with PS values and increased flexibility. .

PS was offered as a time-limited intervention, with a pre-agreed number of sessions (typically 8 PS sessions, with a midway review) to support maintaining boundaries, and the navigation of endings from the beginning. Decisions to consider ending early, or to extend, were discussed in supervision and agreed on a case-by-case basis.

All clinicians from within the MDT were able to refer to the PS pathway. Client allocations were determined by PSW caseload capacity, and were assigned as part of a weekly PS huddle.

All clients who accessed PS were supported using a recovery- orientated approach recognising recovery as a personal and non-linear process rather than a purely clinical outcome.

All clients who accessed PS were supported using a transdiagnostic approach, ensuring that support was not restricted to any single diagnostic category and was accessible across presentations.

The PS Pathway continues to evolve through structured supervision and service-user feedback. Despite this progress, a structured qualitative evaluation of clients’ experiences has not yet been undertaken.

Given the heterogeneity of PS implementation and the limited qualitative exploration of client experiences, this study aims to provide an in-depth understanding of how PS may support recovery in individuals with eating disorders.

This study aims to explore the experiences and perceived impact of 1–1 PS among clients engaged in the Eating Disorders Unit (EDU) outpatient and day care services.

The study explores lived experience perspectives on how peer support is experienced and what processes are perceived as most meaningful, with implications for advancing conceptual clarity around peer support and informing its implementation within eating disorder services.

The primary research questions are as follows:

What are clients’ subjective experiences of receiving 1–1 PS?

How do clients perceive the influence of one-to-one peer support on their engagement with treatment, coping strategies, and broader psychosocial wellbeing”

Methods

Study design

This qualitative evaluation adopted a constructivist–interpretivist epistemological stance, recognising that experiences of peer support (PS) and recovery are socially constructed and co-created through interaction. This approach aligns with the study’s aim to explore subjective experiences of 1–1 PS from the perspectives of individuals with eating disorders.

The study was guided by reflexive thematic analysis following Braun and Clarke’s approach (2021) [37]. This method supports an exploratory, experiential focus and acknowledges the researcher’s active role in meaning-making.

Reflexivity and researcher positionality

Given the interpretive nature of thematic analysis, all researchers reflected on how their positionality could influence study design, data collection, analysis, and interpretation. The research team comprised one trainee clinical psychologist, two cognitive behavioural therapists, one peer-support worker, and one psychology practitioner. Author CL is a Chinese, cisgender female trainee clinical psychologist with an interest in peer-led recovery approaches and experience providing psychological treatment for adults with eating disorders. CP is a British, cisgender female cognitive behavioural therapist specialising in eating disorders, with personal lived experience of eating disorder recovery. GF is a British, non-binary, senior peer support worker. AA is an Indian, cisgender female cognitive behavioural therapist specialising in eating disorders with a particular interest in approaches informed by lived experience. AB is a British cisgender Assistant Psychologist. As a team, we have substantial knowledge and experience of working with eating disorders; these backgrounds may have shaped preconceptions about PS for eating disorders.

To support reflexivity, CL, CP and GF discussed their positionality throughout the study to minimise the impact of preconceptions and potential biases. For example, when designing the interview schedule the team reflected on members’ lived experience and clinical involvement with PS, which informed choices of topics, terms and prompts. Additionally, the interview protocol was reviewed and approved by the Trust’s central PS team.

To foster an open interview environment and reduce potential inhibition in sharing critical views, the interviewer (CL)—who had no prior relationship with participants—emphasised confidentiality and anonymity at the start of each interview. During analysis and write-up, supervision and consultation were sought from senior clinicians and researchers external to the PS team and the wider EDU. Themes and interpretations were discussed to ensure they were grounded in participants’ accounts rather than programme expectations.

Ethics

Ethical approval for the evaluation was granted by the Clinical Director of the Psychological Medicine and Older Adults Directorate Clinical Governance Team at South London and Maudsley NHS Foundation Trust. Upon registration and recruitment, all participants provided written and/or oral informed consent to participate and be recorded for the evaluation. All the results are presented anonymously.

Participants

Inclusion criteria were: (1) adults with a primary diagnosis of an eating disorder; (2) currently receiving, or having recently completed, a 1–1 PS intervention through the outpatient and/or day care service; and (3) having completed the PS intervention within one month prior to the project start date or scheduled to complete it within two weeks of that date.

Because individuals may be referred to PS at any point after their initial assessment at the eating disorder unit, participants were at various stages of treatment (i.e., before, during or after other eating disorder-focused treatments such as CBT-E or the daycare programme).

All fifteen eligible clients were invited to take part. Three did not respond to the invitation despite multiple reminders. Twelve participated, reflecting diversity in gender, neurodivergence and treatment stage (see Result section). Sample size was shaped by pragmatic service constraints and guided by the principle of information power (Malterud et al., 2016) [38], given the focused research aim, a relatively homogeneous sample (all receiving PS for eating disorders), and in-depth interviews.

Procedures

Eligible participants were initially informed about the project by their PSWs. Formal invitations were then sent by researcher CL via e-mail and telephone. This recruitment route may have preferentially reached individuals with more positive experiences. We acknowledge this as a potential source of recruitment bias. Participation was voluntary and separate from treatment.

Semi-structured interviews were conducted after completion of PS sessions.

Interviews were held face-to-face, via video call, or by telephone, and lasted 32–55 min. All interviews were audio-recorded and transcribed verbatim.

Cultural, equality, diversity and inclusion (CEDI) considerations were integrated into the design to ensure accessibility and sensitivity to participants’ identities. To increase accessibility an equivalent online evaluation form was offered as an alternative and one participant chose this option.

Materials

A semi-structured interview protocol of open-ended questions was co-designed with the eating disorder PS team and the Trust’s central PS team. Project objectives, themes emerging from the literature, and anecdotal feedback from previous PS clients were considered when devising topics and prompts. Questions explored perceived benefits, challenges and mechanisms of PS. The online evaluation form contained the same questions and prompts.

Data analysis

Audio recordings from the 12 interviews were transcribed and imported into NVivo. One participant completed the evaluation form online. All data were analysed using reflexive thematic analysis (Braun and Clarke 2021) [37]. Analysis was primarily inductive and semantic at early stages—focusing on surface meanings in participants’ accounts—and later incorporated a latent lens to interpret shared underlying meanings around recovery, hope and relational processes.

The analytic process comprised 5 steps, namely familiarisation with the data, systematic line-by-line coding, developing initial themes, reviewing and refining themes across the dataset, and defining and naming final themes. Codes were consolidated into broader themes without applying predefined theoretical assumptions. Themes were iteratively assessed and refined (including recoding where necessary) to ensure coherence and adequacy of coverage. The online form (n = 1) was analysed using the same inductive coding approach and reviewed alongside interview data. Interview transcripts remained the primary dataset due to greater depth.

CL was the primary coder and analyst. A reflexive single-coder approach was used with analytic consultation from the research team and supervision by senior clinicians/researchers to enhance rigour through critical discussion rather than consensus coding. Iterative theme refinement was undertaken to support transparency and credibility. The study adhered to COREQ principles and reflexive qualitative research standards (Tong et al. 2007) [39] to enhance transparency, credibility and trustworthiness.

Results

Analytic approach and orientation

Consistent with a reflexive thematic analysis (Braun and Clarke 2021) [37], the Results focus on participants’ meaning-making and the relational and contextual processes through which PS was experienced. Themes are presented as interpretive patterns of shared meaning rather than simple summaries of reported benefits. Where participants described changes in symptoms, motivation, or behaviour, these accounts are framed as perceived and subjective experiences rather than evidence of intervention effectiveness.

Participant characteristics

Twelve clients participated in the evaluation: 58.3% identified as female, 25% as male and 16.7% as other. The participants ranged in age from 19 to 40 years (M = 27.7, SD = 7.4). With respect to ethnicity, 50% identified as White British, 16.7% as British Asian, 16.7% as Black British, 8.3% as White Hungarian and 8.3% as White‒Black Caribbean. In terms of neurodivergence, 33.3% had a diagnosis of autism spectrum disorder (ASD), 8.3% had attention deficit hyperactivity disorder (ADHD), and 8.3% reported neurodivergent traits.

Eleven participants were interviewed online, while one chose to complete an online evaluation form.

The number of PS sessions attended ranged from 5 to 14 (M = 9, SD = 2.6). Most participants (58.3%) received PS face-to-face, 16.7% received it through remote video sessions, and 25% engaged in a blended format combining both face-to-face and remote support. Session frequency also varied: 41.7% received fortnightly sessions, 33.3% received weekly sessions, and 25% received sessions at varying frequencies.

At the time of engaging in PS, participants were different stages and models of treatment for their eating disorders. Specifically, 50% in a daycare programme (a recovery focused group based treatment programme for people with eating disorders), 33.3% receiving 1:1 outpatient psychological therapy (including evidence based eating disorder treatment interventions such as CBT-E, MANTRA, including PEACE Pathway adaptions, consistent with service pathways), and the remaining 16.7% awaiting 1:1 outpatient psychological therapy (including for CBT-E, and CAT, therapy). An additional PS group offered by the same PS team was routinely delivered as part of the daycare programme; thereby the 6 participants from daycare received both group and 1–1 PS. PS was therefore experienced alongside, before, or between other interventions, shaping how participants understood its role within their wider recovery journeys.

Overview of themes

Seven interrelated themes captured how participants understood and experienced 1–1 PS: (1) relational understanding and normalisation, (2) informality and shared power, (3) re-positioning the eating disorder within a wider life, (4) safety and non-judgement, (5) imagining recovery through lived example, (6) practical knowledge as relationally embedded, and (7) multi-layered relatability. Table 1 illustrates the seven key themes and associated sub-themes. These themes are overlapping rather than discrete and reflect relational, motivational, and identity related processes rather than linear outcomes.

Table 1.

Themes and subthemes of clients’ experiences of 1–1 PS

NO.	Theme and subthemes
1	Relational understanding and normalisation Complete understanding Normalisation of symptoms
2	Informality and shared power Flexible approach Empowerment to lead
3	Re-positioning the eating disorder within a wider life Connecting to wider life Reduced eating disorder symptoms
4	Safety and non-judgement Safe to disclose Greater receptiveness to support
5	Imagining recovery through lived example Role model Concrete recovery path
6	Practical knowledge as relationally embedded Insights, techniques and skills Practice and implementation
7	Multi-layered relatability Lived experience of eating disorders Other identities

Theme 1: Relational understanding and normalisation

Participants described PS as qualitatively different from other professional relationships because understanding was assumed rather than explained. Shared lived experience appeared to reduce the need for justification or translation of eating disorder thoughts, enabling participants to speak more openly. This relational recognition supported a reframing of eating disorder experiences as understandable responses rather than personal failings, reducing shame and self-criticism.

Rather than describing validation alone, participants articulated a shift in how they understood themselves in relation to their diagnosis. Normalisation functioned as a meaning-making process that separated identity from illness, allowing participants to see their difficulties as shared and survivable rather than defining.

“It definitely changes things to know that the person on the other side completely understands where you’re coming from and just allowed me to be a lot more open and honest in the way I guess I wouldn’t be with other staff members.”

Theme 2: Informality and shared power

Participants consistently emphasised the more informal nature of PS. Informality was not merely logistical (e.g. meeting in cafés, flexibility in session duration, frequency and delivery method) but symbolic of a redistribution of power. The absence of a prescriptive agenda allowed participants to position themselves as active agents rather than recipients of treatment (e.g. client-led topics and person-centred dynamic). This contrasted with experiences of highly structured therapies, which some associated with performance pressure or fear of failure.

Informality therefore functioned as a relational mechanism through which participants experienced autonomy, choice, and collaboration. This appeared to support engagement and openness, particularly for participants who felt overwhelmed or disengaged from formal treatment structures.

“It was tailored to me, because other treatment can be very like prescriptive, like following a manual and numbers based, but with XX (PSW) I could think about things that I wanted to work on and we could work on it at my own pace, so that was good.”

Theme 3: Re-positioning the eating disorder within a wider life

Participants frequently spoke about PS as helping them locate their eating disorder within a broader life context. Rather than focusing exclusively on symptom management, PS conversations supported reflection on identity, values, and relationships. Participants described reconnecting with interests, social roles, and future aspirations, which altered how dominant the eating disorder felt in their lives.

Where participants reported changes in eating disorder behaviours, these were embedded within narratives of increased self-understanding and motivation. Such accounts are presented here as subjective experiences of change, illustrating how participants made sense of progress rather than evidencing treatment effects.

“XX (PSW) really encouraged me to lean into my hobbies and interests, like I started roller skating, seeing my friends a lot more. Just like putting myself out there and having a bit more confidence in myself.”

“By the end of our last session, I’d not binged or purged for two weeks, which is the longest I’ve ever gone in my whole life.”

Theme 4: Safety and non-judgement

Some participants reported feeling unsure of the boundaries of PS before starting the sessions, with worries that the sessions may be triggering either for themselves, or PSW. However, participants reported that boundaries of the PS roles was addressed sensitively by the PSW as part of the sessions, thus enabling the spaces to feel safe.

“A bit apprehensive about triggering my worries & ED….Reality was totally different, feeling very safe”.

Participants described PS as creating a space in which previously concealed thoughts could be voiced. Safety was linked to confidence that disclosures would not lead to punitive responses, loss of care, or moral judgement. This enabled exploration of ambivalence, relapse fears, and shame laden experiences.

Several participants described increased openness with other professionals following PS. Rather than positioning PS as causing improved engagement, participants framed it as a practice space in which honesty felt safer, subsequently shaping how they approached other therapeutic relationships.

“I’m way more open to my therapist now. I used to be a lot closed off, not always telling the truth… I’m a lot more open now because I learned you need to be open with your fears to actually get to the root of the issues. Without (PSW), that wouldn’t have happened.”

Theme 5: Imagining recovery through lived example

Seeing a PSW who identified as ‘in recovery’ and ‘recovered’ allowed participants to imagine recovery as tangible, achievable and non-linear. Importantly, participants emphasised that hope was generated not only through symptom resolution but through exposure to a meaningful post recovery life. Recovery was therefore understood as the presence of valued living rather than the absence of eating disorder symptoms.

Participants described drawing on PSWs’ narratives during periods of doubt or relapse (e.g. reassurance, reminders and support in recognising personal strengths and progress). These accounts are framed as perceived motivational supports rather than evidence of sustained change.

“As well as the role model aspect, it wasn’t just about XX (PSW) having recovered from an eating disorder… it’s everything that was her life after recovery and hearing about all of the things that she had been able to achieve from being eating disorder free. I think that was really inspiring.”

“I think XX (PSW) is kind of confident in me and helps me to see the characteristics, strengths and determination that I do have that I can put towards recovery.”

Theme 6: Practical knowledge as relationally embedded

Participants valued practical strategies shared by PSWs (e.g. improving communication around eating disorder feelings and needs to others, and coping with weight and shape changes). However, these were described as effective because they were relationally situated. Advice felt credible because it was grounded in lived experience and tailored collaboratively. Practising skills together (e.g. eating in public spaces) reduced fear and increased confidence, not through instruction alone but through shared enactment.

This theme highlights that increased confidence in the practical strategies shared in PS sessions was linked to relational trust and mutual understanding.

“The skills and techniques that XX (PSW) shared were useful, from new perspectives of viewing eating disorder and recovery, and actual practical approaches to getting better.”

“Because of XX’s (PSW) own autism so she knows why I struggled with food due to my autism. I don’t like things with strong flavours or having too much going on. She was able to suggest food that I didn’t even think of but was willing to try.”

Theme 7: Multi-layered relatability

Relatability extended beyond eating disorder experience to include gender identity, sexuality, neurodivergence, and cultural background. Shared or understood identities helped participants contextualise their eating difficulties within broader experiences of difference, marginalisation, or sensory sensitivity.

Rather than viewing (unplanned) matching as a discrete intervention component, participants described relatability as emergent and meaningful when it resonated with their own identity narratives.

“Because of my new diagnosis (of autism), I didn’t really understand the connections between my eating disorder and other illnesses, until she (PSW) used her own autism to highlight that to me, kind of helping me put things together and start to make sense of many confusions.”

Duration and endings as part of the experience

Participants frequently reflected on the ending of PS. Many described the time limited nature of PS as emotionally difficult, particularly when followed by waiting periods for other treatments. These accounts highlight how PS endings were experienced relationally, shaping feelings of momentum, navigating endings, or readiness rather than simply satisfaction levels. One participant’s interest in becoming a PSW following accessing PS was interpreted as an expression of meaning-making and reciprocity rather than an isolated anecdote.

Development of an eating disorder specific PS feedback tool

Informed by these qualitative themes, the team developed an eight-item feedback questionnaire intended for future service evaluation. The measure is not validated and is not presented as evidence of effectiveness. Instead, it represents an attempt to translate experiential domains valued by participants into structured feedback for ongoing service development (see Table 2).

Table 2.

Eating disorder specific PS feedback questionnaire

In relation to your peer support sessions:	1–10 (1 = not at all, 10 = completely)
1. My feelings and experience with eating difficulties are validated.
2. The sessions are flexible and tailored to my needs.
3. I feel reconnected to other parts of my life outside eating and body.
4. I found it a non-judgemental space.
5. I feel more hopeful and motivated towards my recovery.
6. I gained a better understanding of my eating difficulties.
7. I found the knowledge & strategies shared by my peer support worker helpful.
8. I could relate to my peer support worker.

Discussion

This study explored how individuals receiving 1–1 PS within an eating-disorder service understood and made sense of that experience. Rather than evaluating effectiveness, the findings illuminate relational, identity-based, and motivational processes through which PS was experienced as meaningful. PS was understood as distinct from formal treatment, offering a relational and non-judgmental space characterised by shared understanding, reduced power differentials, and embodied hope. These findings were aligned with previous research [21, 28].

As most participants received concurrent eating-disorder treatments, it is difficult to isolate the specific impact of the 1–1 PS. Some benefits may stem from the synergy between PS and other interventions. Thus, participants’ accounts suggest that PS functioned as a complementary relational resource alongside clinical treatment rather than a stand-alone intervention, as supported by NICE guidelines [40]. Consistent with other qualitative studies [41] and systematic reviews [28, 42] on peer mentoring in eating disorders, peer mentoring appeared to support engagement, self-understanding, and hope, without being framed by participants as replacing therapy or producing guaranteed change.

Although participants described improvements in motivation, confidence, and eating-disorder behaviours, these accounts are best understood as subjective meanings rather than indicators of intervention efficacy. Framing PS as ‘effective’ risks overstating what qualitative data can support. Instead, this study contributes to understanding how PS is experienced and why it may feel helpful to some individuals at various stages of recovery.

The findings can be situated within, and extend, two key strands of existing PS literature: (1) effectiveness- and implementation-focused reviews of PS across mental health settings, and (2) outcome-focused evaluations of PS within eating disorder services.

First, the recent umbrella review by Cooper et al. [43] synthesised evidence on the effectiveness, implementation, and experiences of paid PS across mental health services [43]. While that review reported mixed quantitative evidence for clinical effectiveness, it highlighted consistent experiential themes relating to relational value, role ambiguity, and the importance of organisational context. The present study complements and deepens these findings by offering an in-depth, service-user-focused exploration of how such relational value is experienced in eating disorder services. In particular, themes of informality, shared power, and safety echo Cooper et al.’s experiential synthesis, while providing greater analytic detail regarding the meaning-making processes through which these qualities are perceived as helpful.

Importantly, Cooper et al. [43] emphasised that associations between PS content and measurable outcomes remain unclear, and cautioned against over-reliance on effectiveness claims given the generally low quality of existing reviews. This reinforces the interpretive positioning of the current study: rather than contributing to debates about efficacy, our findings illuminate the relational and identity-based mechanisms that participants themselves described as meaningful, thereby addressing a gap identified in the umbrella review regarding experiential depth and theory-building.

Second, outcome-focused eating disorder PS research, including the 2024 evaluation reporting improved symptomatology and reduced hospital admissions, demonstrates that PS can be associated with favourable service-level and clinical indicators. While valuable, such studies necessarily prioritise measurable outcomes and service impact. The present qualitative findings extend this literature by foregrounding participants’ lived experiences of peer mentoring, illustrating how perceived benefits (e.g. increased hope, reduced shame, greater openness) are understood and integrated into everyday recovery narratives.

Rather than positioning experiential accounts as evidence of effectiveness, this study offers insight into the subjective processes that may help explain why PS is experienced as acceptable and meaningful by many service users. In doing so, it complements outcome-focused eating disorder studies by articulating the relational and contextual dimensions that are often under-theorised in quantitative evaluations.

Together, these literatures suggest that PS in eating disorder services should be understood not only in terms of potential outcomes, but as a relational practice embedded within wider treatment pathways, organisational structures, and identity processes. By centring lived experience, the present study contributes a necessary qualitative counterpoint to effectiveness-dominated discourses, responding directly to calls within the PS literature for greater attention to experiential and interpretive dimensions.

Limitations

This exploratory study offers rich insights but has several limitations. Participants were at varying treatment stages and receiving different eating disorder therapies. This diversity shaped how PS was understood and limits claims about specificity. Additionally, individuals who declined or withdrew from PS were not included; their perspectives may have differed, potentially reflecting unmet needs, ambivalence about peer roles, or mismatches in expectations. This, along with PSWs recruiting their own clients, may have introduced self-selection and social desirability bias, which are common among eating disorder clients [44]. These should be considered when interpreting the findings.

Furthermore, the small, heterogeneous sample (n = 12) varied in terms of diagnosis, severity, and treatment stage, potentially limiting both the generalisability and validity of the findings. Shared identity traits (e.g., neurodiversity) were mentioned positively, and anecdotal data suggest a higher referral rate of neurodivergent individuals to PS. This highlights the need for subgroup-specific evaluations.

Implications and future research

Findings suggest that PS may be particularly valuable as a relational and meaning-making space within eating-disorder services. However, there remains limited evidence for the efficacy and implementation of practices. This study sheds some light on clinical implications and future research directions.

While flexibility in the delivery of PS aligns with person-centred care, it also introduces logistical challenges.

Regarding participants’ wishes for additional PS sessions, or repeat access, it poses a challenge in balancing demand, clinical resources, and client expectations. To enhance efficiency, services should clarify PSs structure, and duration upfront, and be informed by understanding its mechanisms of change.

Further standardisation may be needed, and evidence-based PS protocols should be guided by both research and lived experienced perspectives. A co-created shared framework involving service users, peer workers, healthcare professionals, commissioners, and researchers may improve consistency [21, 45].

Interestingly, the perceived benefit of multi-layered relatability from unplanned matching on identity characteristics (e.g., gender, neurodiversity) calls for more attention from research and eating disorder services, responding to the diversity of clients, including underrepresented groups, although structured guidance on PS for diverse populations remains limited.

While this study focused on clients, existing research indicates that PSWs can experience emotional strain [21, 46], highlighting the importance of including PSW perspectives. Importantly, ImROC (Implementing Recovery through Organisational Change) emphasises the need to consider the impact of the organisational systems within which PSWs operate [45], upon them.

As services and research continue to evolve, there is a growing need for future research to recognise lived experience not only as an adjunct to established therapeutic modalities, but as a form of expertise in its own right, capable of identifying blind spots and shaping more responsive models of care [45, 47].

PSWs themselves can offer unique and multi-layered insights, informed both by their experiences of accessing services, and their roles in delivering support as part of them.

Future research should include those who disengage from PS and examine how PS interacts with different therapeutic modalities. As the emergence of alternative delivery models, such as single-session PS in the broader trends in eating disorder care [48], stratified analyses based on PS type or stage of treatment could yield more targeted insights. Longitudinal qualitative designs could further explore how meanings attributed to PS evolve over time [22].

The development of an eating disorder specific PS feedback tool should be understood as a future oriented outcome of this qualitative work. Its purpose is to capture domains of experience that participants identified as meaningful.

The tool aims to capture process-level mechanisms and domains that reflect core relational and experiential components that are difficult to capture using standard clinical outcomes measures, yet are frequently identified by service users as critical to engagement, motivation and sustained recovery [45] and aligns with IMROC’s calls for future research to focus on understanding the ingredients of peer support that make it acceptable, accessible and empowering [45, 47].

Future mixed methods studies would be required to examine reliability, validity, and relationships with clinical outcomes.

Conclusion

This qualitative study explored how individuals receiving 1–1 PS within a specialist eating disorder service understood and experienced that support. The findings illuminate the relational, identity-based, and meaning-making processes through which PS was perceived as helpful at multiple different stages of the treatment process. Participants consistently described PS as distinct from formal treatment, characterised by shared understanding, informality, reduced power differentials, and the embodied presence of hope through lived experience.

Across themes, PS was experienced not as a replacement for clinical intervention but as a complementary relational space that supported openness, self-understanding, and reconnection with valued aspects of life beyond the eating disorder. The perceived value of PS lay less in specific techniques or outcomes, and more in how relational safety, relatability, and collaborative engagement shaped participants’ sense-making and motivation. Importantly, these experiences were embedded within wider treatment pathways, highlighting PS as a contextual and relational practice rather than a discrete intervention with uniform effects.

By centring service users’ accounts, this study responds to calls within the PS literature for greater attention to experiential and interpretive dimensions, particularly within eating disorder services where qualitative evidence remains limited. The findings suggest that understanding how PS is experienced, and why it feels meaningful, may be as important as measuring outcomes when considering its role within recovery-oriented care. User perspective is essential to service improvement and intervention refinement [45]. Future research should continue to integrate qualitative insight with service evaluation to ensure that PS models, and the organisational systems they exist within, remain responsive to the relational and identity-based needs of those they aim to support.

Author contributions

Cheng Liu, Catherine Perry and Georgia Faulkner participated in the design of the study. Cheng Liu performed the statistical analyses and drafted the manuscript.Project administration: Aria Awwal, Annabelle Beswick.All authors read, edited, reviewed and approved the final manuscript.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. All authors are employed by South London and Maudsley NHS Foundation Trust, which provided institutional support in the form of author time.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for the evaluation was granted by the Clinical Director of the Psychological Medicine and Older Adults Directorate Clinical Governance Team at South London and Maudsley NHS Foundation Trust. Upon registration and recruitment, all participants provided written and/or oral informed consent to participate and be recorded for the evaluation. All the results are presented anonymously.

Competing interests

The authors declare no competing interests.

Conflict of interest

All authors declare that they have no competing interests.