The “Clinical Ceiling” Blocking Lived Experience Leadership in Mental Health

Despite decades of policy promises, people with lived experience still struggle to shape the mental health systems that claim to value their expertise. A new perspective article in the International Journal of Mental Health Nursing argues that many are pressed up against what the authors call a “clinical ceiling” – an invisible barrier that keeps lived experience approaches from exercising real authority, even when organizations say they want reform.

“Under the clinical ceiling, lived experience-led approaches can only influence so far because they counter the hegemonic clinical practice models and ideologies focused narrowly on a medical model of diagnosis, symptom management, and treatment,” the authors write.

“Attitudinal and structural barriers impede lived experience-led approaches in these settings, highlighted in the expressed and overarching need for clinical governance, which maintains the status quo and systemic power within traditional models of mental health service delivery. In practice, this means the clinical ceiling reinforces the clinical practitioner as the expert and, too often, decision-maker for other people’s lives. Under the clinical ceiling, lived experience approaches are limited in how much they can influence reform and systemic change as they are invalidated within the context of the conditions and power structures in which they are applied.”

The paper, “Clinical Ceiling: Barriers to Lived Experience-Led Approaches in the Mental Health Sector,” is written by lived experience leaders Katie Larsen, Helena Roennfeldt, and Debra Carlon from Mind Australia, along with Ellie Hodges from the Lived Experience Leadership and Advocacy Network (LELAN), and Louise Byrne, who holds appointments with Lived Experience Training in Queensland and the Program for Recovery and Community Health at Yale School of Medicine.

They write from within the system, drawing on their work developing lived-experience governance and practice frameworks at Mind Australia and their broader advocacy within Australia’s lived-experience movement. Their central claim is that current reforms have stalled because clinical hierarchies, risk regimes, and biomedical assumptions still define what counts as “real” knowledge and power in mental health care. The clinical ceiling, they argue, is what makes that leadership so hard to realize in practice.

The authors examine why lived-experience leadership remains constrained despite growing recognition of the failures of biomedical psychiatry and increasing policy imperatives for lived-experience involvement. Drawing on their insider perspectives as lived experience leaders, they identify systemic barriers that prevent lived experience approaches from achieving meaningful authority in mental health systems.

They borrow the metaphor of the “glass ceiling” from gender studies and adapt it to mental health. Here, the barrier is not sex but the presumed ontological authority of biomedical psychiatry. Clinical qualifications, diagnostic systems, and risk-management frameworks are treated as the only legitimate basis for leadership, while lived experience is welcomed as “input” but rarely as a foundation for decision-making.

Under this ceiling, lived experience workers are often clustered in peer support roles with limited scope and little formal power. In some services, lived experience executives now exist on organizational charts, but the authors note that these posts may lack control over budgets, staffing, or strategy.

Services advertise their commitment to co-production and recovery, but clinical hierarchies remain intact. Lived experience is highlighted in brochures and policy documents, yet sidelined when it clashes with dominant practice models.

The authors trace how lived experience roles in Australia have grown but remain concentrated in peer support positions, with significant underrepresentation in senior management and leadership. Even when lived experience leaders do hold positions of authority, they often lack actual decision-making power and operate within severely limited scopes of practice.

The clinical ceiling operates through several interconnected mechanisms. First, clinical governance frameworks are treated as non-negotiable requirements in mental health settings, automatically privileging biomedical paradigms. This perpetuates what the authors describe as “epistemic injustice”—the systematic dismissal of lived experience knowledge as less legitimate than clinical expertise.

Second, the biomedical model’s focus on diagnosis, symptom management, and risk containment fundamentally conflicts with lived-experience approaches grounded in human rights, social justice, relationships, and connection. The authors note that lived experience approaches locate distress within sociocultural and political contexts, acknowledging racism, discrimination, marginalization, trauma, and the ongoing impacts of colonization—perspectives that directly challenge psychiatry’s individualized, biological framing.

“The medical model perpetuates a deficit approach and low expectations for people based on a limited prognosis for recovery and a focus on biological causes rather than on what has happened to people,” the authors write.

Third, even in settings explicitly designed as alternatives to hospitals and emergency departments, the clinical ceiling reasserts itself. Attitudinal and structural barriers ensure that clinical practitioners remain positioned as the ultimate experts and decision-makers, while lived experience approaches are either diluted or co-opted within dominant biomedical systems.

The authors provide concrete examples of lived experience-led transformation from Mind Australia’s advocacy work, including approaches that:

• Locate distress as interconnected with sociocultural and political experiences, acknowledging the role of racism, discrimination, marginalization, trauma, and the ongoing impacts of colonization
• Radically disrupt and repair the impacts of a mental health system that is culturally unsafe, coercive, and dominated by biomedical approaches.
• Offer ways of working grounded in love, compassion, and connection, creating space for people to trust themselves and understand their experience.s

The authors argue that implementing these approaches requires “the courage to take risks, challenge longstanding power hierarchies, move beyond biomedical framing and its associated responses, centre intersectionality, human rights, and justice, trust in the voices of those who have lived experience, and demonstrate courage to step into new ways of being and doing.”

The authors acknowledge their positionality as insiders within designated lived experience leadership roles, which provides valuable first-person accounts of barriers to lived experience leadership but may also reflect experiences specific to the Australian context, where lived experience workforce development has progressed further than in many other countries, including the United States.

The authors briefly mention that biomedical dominance dismisses knowledge and wisdom from First Nations, multicultural, and queer communities, but do not extensively explore how the clinical ceiling operates differently for lived experience workers from marginalized communities who face compounding forms of discrimination. The intersection of the clinical ceiling with racism, colonization, and other systems of oppression deserves deeper examination, particularly given that people from marginalized communities are disproportionately subjected to coercive psychiatric interventions.

Additionally, while the authors call for lived-experience leadership and radical systemic transformation, they do not fully address the risks of professionalization, which can create new hierarchies within the lived-experience workforce—potentially excluding people whose experiences or approaches don’t align with emerging professional standards or credentialing requirements.

The clinical ceiling concept builds on extensive documentation of barriers to lived experience leadership in mental health systems. Previous research has shown how peer support roles risk being co-opted by clinical systems, losing their radical potential when they’re forced to operate within biomedical frameworks. Studies have documented how peer workers must be “just mad enough”—appearing stable enough to satisfy institutional expectations while maintaining enough visible distress to relate to service users, creating impossible contradictions that undermine their work.

Research reveals that tokenism is widespread in participatory mental health research, with stakeholders expressing deep concerns about the lack of genuine power-sharing and the insufficient funding and training for lived experience involvement. When peer supporters face systemic hurdles in digital mental health initiatives, the research confirms that inclusion without infrastructure is tokenism, not transformation.

The authors’ call to “smash through the clinical ceiling” demands a redistribution of power, investment in lived-experience leadership, and the courage to fundamentally reimagine how we understand and respond to human distress. It demands belonging, not merely accepting and including. Without addressing these deep structural barriers, lived experience involvement will remain what the authors call “tokenistic inclusion”—symbolic gestures that leave existing power hierarchies fully intact.

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Larsen, K., Roennfeldt, H., Carlon, D., Hodges, E., & Byrne, L. (2025). Clinical ceiling: Barriers to lived experience-led approaches in the mental health sector. International Journal of Mental Health Nursing, 34(5), e70159. https://doi.org/10.1111/inm.70159 (Link)