Jan N. DeFehr is an associate professor in the Faculty of Education at the University of Winnipeg and an associate of The Taos Institute and a member of the Faculty for Palestine, Manitoba. She is also a member of the York University Mad Studies Hub. She earned her PhD in Social and Behavioral Sciences from Tilburg University, the Netherlands. Before entering academia, she spent many years as a clinical social worker, working alongside people who were trying to make sense of their distress within, and often in spite of, the mental health system. Her teaching, research, and course development focus on building public access to critical analyses of that system, drawing on the work of clients and survivors of psychiatry, practitioners, and scholars.
Her new book, A Critical Mental Health Primer: Towards Informed Choice in Social Services, Education, and Healthcare (Canadian Scholars, 2025), offers a clear and accessible map of critical mental health scholarship. The book examines scientific critiques of diagnosis, the potential harms of psychiatric labels, the lack of transparency and procedural justice in services, anti-colonial critiques of mental health premises and practices, and the evidence on psychiatric drugs and the DSM. It also gathers non-pathologizing ways of helping that center relational, dialogical, anti-oppressive, and anti-colonial approaches, along with concrete tools for informed choice and everyday support outside of the dominant medical model.
In our conversation, we talk about how Jan came to adopt critical perspectives, why she sees access to critical mental health knowledge as a prerequisite for ethical practice, and what it looks like when organizations take informed choice seriously. We move through the key chapters of the book, explore its implications for social workers, educators, and health professionals, and look at how communities can build forms of care that do not depend on diagnosis or coercion.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Justin Karter: Jan, thank you so much for joining us.
Jan N. DeFehr: Thank you so much for having me. Before we begin, I want to express my heartfelt thanks to Mad in America for the work you’ve done, for so many years, to invite conversation around these topics. Many of us have taken courage, and real substance, from your work. A lot of people are working in isolated pockets, almost like silos, and it makes a difference to know you’re there.
And thank you to you, Justin, for your work as well. I first crossed paths with you through your open letters. That work has shaped my own thinking in a deep way.
Karter: Thank you. It’s meaningful to hear that. Let’s start at the beginning. Could you share a bit about your path into this work? How did you end up in mental health practice, and when did you begin moving toward a more critical perspective?
DeFehr: I started out in classical piano, actually, following in the footsteps of my mother. In my twenties, experiences drew me toward groups of people struggling against different forms of systemic injustice, and I began veering away from that first love and into other fields.
I eventually did a master’s in social work at the University of Manitoba and began a publicly funded counselling practice as a clinical social worker. That kind of service is covered under our socialized medicine in Manitoba, and in many places in Canada.
For a lot of my practitioner work, I was a closeted critic of the mental health system.
In my practice, I started to notice how mental health vocabulary was showing up more and more among practitioners, my colleagues, and also the people meeting with me. People were describing themselves in terms of mental disorders. I even began to hear my own work described as “mental health practice,” and that I occupied a “mental health position” in the community health centre where I worked.
That always felt untruthful to me. Even when people’s struggles were named with mental health terms, we would immediately begin talking about their lives, their relationships, financial realities, economic pressures, social and political contexts.
The “mental” lens felt profoundly decontextualizing, individualizing, pathologizing, and depoliticizing. Those are words I often return to. I became more uncomfortable over time, and more openly critical.
I think I got outed in a situation when I was working in a different setting. I began working in student services at the university where I now teach, as a student counsellor. There were three of us at that time. We had new administration, and they were excited to announce a new “mental health initiative.” It would be cross-campus. Several academics were invited, and also staff. The meetings were large. And the announcement, basically, was that we would have an early detection and treatment of mental illness initiative on campus. Wouldn’t it be great to get more students diagnosed and treated as rapidly as possible?
My counselling colleagues and I were immediately concerned. That might sound wholesome and necessary to many people. We tried to support aspects of it that we felt we could.
Karter: Can you say more about your concerns there? For many people, that might sound like a public health approach. Identify illness early and connect people to care. Why doesn’t that model translate cleanly here? What risks were you worried about when screening college students for diagnoses?
DeFehr: I can imagine people thinking, what could possibly go wrong?
A lot of our concerns had to do with the fact that many students, and many professors too, could meet diagnostic criteria for anxiety or depression at some point in their studies. Knowing what we knew of critiques in the field, we were concerned students would be pushed into the mental health system without access to the critiques and controversies.
I had to come out as a very concerned practitioner. We became isolated in our work. There were formal reprimands meant to bring us in line. Eventually, those administrators moved on. I remained.
Then one day there was a quiet invitation to connect with the Faculty of Education. I learned that the dean at that time was a former school psychologist who was deeply concerned about the medicalization of student distress, especially among students marginalized by colonialism and systemic impoverishment.
A couple conversations later, I was invited into the Faculty of Education. Suddenly, I was teaching courses in mental health, speaking openly, writing, publishing, and researching about topics I had been explicitly forbidden to discuss in student services.
It was a big transition, and it felt risky. My colleagues warned me that school systems are clinical terrain, intertwined with the mental health system. But what I’ve found is that pre-service teachers, in-service teachers, and my faculty colleagues have been overwhelmingly supportive. I’m very grateful.
Karter: Early in the book, you make the point that we often do not know when we are interacting with “the mental health system,” or when we’re being interpreted through psychological or psychiatric language. Schools are one place where that can happen. Teachers may not formally diagnose, but they are often asked to observe students in ways that later become part of an assessment.
You argue there’s a lack of transparency about when we come under this kind of gaze, and what can follow from it, sometimes in ways people do not anticipate.
Could we back up for a moment and talk about how this book came to be? At times it reads like something you wish you could have handed your former self in student services. How did you come to write it?
DeFehr: Partly through the experience of teaching critical mental health courses for pre-service and in-service teachers, and realizing what I also saw in practice, that people don’t have access to critical research in the field.
I hear this feedback regularly: Why are we only hearing about this now?
The field is often presented as coherent and unified. People aren’t told that it’s profoundly divided, and that it always has been.
My conviction is that members of the public deserve access to that critique. When we present mental health premises and practices through curriculum, or through awareness campaigns, and we skip over critical scholarship, we are breaching the principle of informed consent.
I wanted to create a resource for educators and professionals, but also something accessible for people less familiar with the field. Professional ethics require full disclosure of relevant information, especially information about risk of harm. But professionals can’t do that if their education never gave them any opportunity to engage critical scholarship. That was part of it too.
Karter: You make a strong case that critical mental health knowledge is required for ethical practice, because it’s necessary for meaningful informed consent. I wonder if you could describe what that looks like in practice.
For example, someone may come into primary care, be screened for depression, and then be referred for a conversation about diagnosis, therapy, or medication. In those early encounters, what do you think is typically presented? And what might someone trained in the material you cover do differently to support more informed choice?
DeFehr: Informed consent ethics are nothing new. Many organizations have forms and checklists. A lot of those exist to cover liability.
Mostly, though, consent happens through implied consent, like it does in other areas of medicine. If you book with an oncologist, you don’t need to offer explicit permission to receive a cancer diagnosis. Your consent is implied with the booking of the appointment.
Psychiatry and the broader mental health field often adopt that same practice, even though they are working from a very different evidence base.
The concern with implied consent is that it’s not much of consent at all. People don’t understand who the mental health professional is, because it’s such a multidisciplinary field.
Someone might disclose to their family physician that they’ve been sleeping poorly, or feeling low because of a loss or abrupt changes. People do not understand that they’re speaking with someone authorized by the state to begin a mental health history, or add to it. Assessment may already be underway, and there’s nothing that signals, “My mental normalcy is now being assessed.”
People don’t understand who the diagnosticians are in their agencies. They don’t understand how the process works. And they don’t understand that explicit consent to psychiatric assessment is often not required. It begins with questions.
As Allen Frances has mentioned, especially in medical settings, it can happen quickly and quietly within appointments that may be eight to ten minutes long.
You can leave with two or three diagnoses entered into your record.
People tend to understand the potential for help. The potential for harm is a mystery to many.
The book argues for moving beyond informed consent to an informed choice standard of care. People need the opportunity to consider potential benefit and potential harm.
For example, they need to understand the permanence of a DSM diagnosis, and that it can work differently than many diagnoses in other areas of medicine. In many systems, there isn’t a straightforward mechanism to remove the diagnosis after it enters the record. The possibilities are often framed in terms of remission or relapse. You can add labels, but you cannot easily delete them.
People also need to understand there can be vocational, financial, legal, and relational consequences that can play out decades after a diagnosis is assigned.
Karter: Let’s stay with diagnosis, because you start the book there. Why begin with diagnosis? And what do you think most people do not know about diagnosis that they would need to know for the kind of informed choice you’re describing?
DeFehr: The book lays out a scientific critique of diagnosis.
There are a couple things I think people need to be clear about, and sometimes they’re not even clear in critical settings.
First, we do not have scientifically valid biomarker evidence of pathology for mental illness diagnoses, with the exception of a small handful, maybe five or fewer out of hundreds.
A related critique is that these diagnoses in the diagnostic manual are not made on the basis of lab tests. We don’t have lab tests or objective medical tests available, or required, for DSM psychiatric diagnoses. Not for schizophrenia, bipolar, attention deficit disorder or ADHD, the depression diagnoses, and so on.
We have never had a test for chemical imbalance.
That does not mean people’s suffering isn’t real or valid. It means we don’t have adequate evidence to medicalize people’s distress and behaviors that may be debilitating or perplexing.
The scientific critique is foundational, not because science is the final word, but because it’s important to understand we have not established valid biomarker evidence that could be measured in a lab.
The discourse is often that someone “has ADHD,” as though we carry a psychiatric infection in our genes or neurology or biochemistry. People deserve clarity about what we can and cannot claim, scientifically.
Karter: Once you begin there, it can unsettle the assumption that these are settled disorders, discrete conditions treated like other medical diagnoses. And once that assumption loosens, people can become more open to alternatives and to different ways of naming.
From there, you move into anti-colonial critiques and context. Could you speak to that part of your book, and how your location and experiences in Canada shaped your approach?
DeFehr: I was influenced by Ameil Joseph’s work. He’s a professor in social work at McMaster University. He offered a critique of critical movements in psychiatry and mental health, that they have not said much about colonialism, just as psychiatry tends to omit it.
Yet many argue colonialism is one of the greatest forces shaping misery and distress around the world, especially given what some scholars describe as a kind of global apartheid.
I am a settler teaching on stolen land, the land of the Anishinaabeg, the Anishinaabemowin, Inuik, Nehethuik, Oceti, Shakowin, Dakota Oyate, and Michif peoples on Treaty One territory, national homeland of the Red River Métis.
As a colonial settler, as a white settler, I have a responsibility.
I don’t think of it as activism. I understand it as duty. A duty to understand decolonial critiques, and to ensure the work is not superficial or only about optics, as it often is in our country.
For me, that connects with land back, Indigenous land defense, and water protection movements. It includes contributing financially and showing up with my whole being, not just in Canada, but elsewhere in the world.
Those of us who consider ourselves anti-colonial scholars where I work have an obligation to oppose colonialism around the world, and to work in solidarity with oppressed peoples.
Karter: How do you see the mental health system as connected to colonialism, both in the ways it can reinforce that project and, if you think it can, in the ways it might also interrupt it?
DeFehr: The mental health system often frames Indigenous distress as a therapy issue, as a signal of damage and deficit. It frames the need as shortages in mental health services. If only we had more mental health professionals.
Instead of recognizing how systems and structures produce distress.
That word distress feels too small, honestly. The colonial system holds many people barely in survival.
I’m influenced by Arthur Manuel’s work. He is the late Secwepemc leader. I refer to his writing in the primer. He writes about dispossession and dependence on the state as defining features of colonial Canada. He writes about what he calls the 99.8 system, where the colonial state controls almost all of the land mass, while Indigenous peoples have care of roughly 0.2%.
That produces massive impoverishment and forces many people to live at a survival and crisis level.
A big part of the critique is how the mental health system takes collective Indigenous distress and launders it into individual pathology. It decontextualizes it, pathologizes it, and makes assumptions about deficit.
In the book, I also explore colonial place naming. I started thinking about diagnostic practices as a naming practice. Mental health professionals routinely place names on people, names that come from the American Psychiatric Association.
Why are we placing these labels on non-Americans, on people from different cultures, on Indigenous peoples, without informed consent and without opportunity for informed choice?
I began to think of diagnoses assigned to Indigenous peoples in a non-consensual manner, which is virtually all the time, as a continuation of colonial place naming.
Karter: You raise the question of what a name does, materially and psychologically. What happens when we rename something, whether it’s land or a human experience? What are the consequences of importing a diagnostic taxonomy created in a particular historical and cultural moment and applying it broadly?
DeFehr: Leanne Betasamosake Simpson has written about naming as connected to ownership.
I’m also thinking of the group Emotions Are Not Illnesses, ERNI. They describe diagnostic naming as a kind of identity theft. Many people don’t have a memory of themselves apart from a diagnosis assigned in second grade. They don’t have a way to understand themselves apart from being psychiatric subjects.
Of course, for many people, a diagnosis has been beneficial within our systems. But for many others, the assignment was a form of theft. It takes something that belongs to the person, and to us collectively, our feelings, behaviors, our weirdness, and suddenly names it as psychiatric.
After that happens, there is no mechanism to take it back, at least officially. Individuals do it for themselves in many ways, and there are acts of resistance. But on the record, as Kenneth Gergen wrote decades ago, the person is now regarded as less than ideal.
No anti-stigma campaign is going to save someone when they realize, I wanted this vocation, but now I can’t get professional licensure because of a diagnosis entered in eighth grade. Or my life or disability insurance is more expensive. Or I’m not eligible. Or my diagnosis is now in a child custody hearing. Or I wanted to adopt, but my mental health history must be disclosed and counts against me.
There are many material consequences beyond how we understand ourselves. People usually don’t get a chance to consider them before they attend a mental health consult.
Karter: That naming can also imply a certain kind of response. It can start what Rachel Aviv has called a “career” as a psychiatric patient, and that often entails medication.
Your next chapter takes up psychiatric drugs and standards of care. What was it like to approach that literature and write about it as a non-prescriber? And why was it essential to include?
DeFehr: People may notice my background and be surprised there’s a chapter on psychiatric drugs. I’m not a prescriber. I never have been. I’m not a pharmacist.
But many people doing critical academic work related to psychiatric drugs have never been prescribers. It’s not a prerequisite to think critically about a system.
You don’t have to have membership in that system to study it.
I have colleagues in criminology who do critical work on policing. They have not been police officers. That isn’t required for academic critique.
I’m not alone in this. I think of James Davies, for example. His background is anthropology and he’s a psychotherapist, if the information online is correct.
Also John Read, who has contributed so much as a psychologist and academic. Also not a prescriber.
There’s a lot of critical scholarship and research available to the public that doesn’t require degrees in pharmacology to understand and use.
I’m grateful for peer review. I’m also grateful for my spouse, who is a community health physician. We’ve been in conversation about these matters for over 35 years. I’m grateful for conversations with prescribers too. Many of us have been learning together.
There are also resources available to people, including guidance for psychological therapists on conversations with clients who are taking or withdrawing from prescribed psychiatric drugs. And Mad in America has made a lot of this knowledge accessible as well.
Karter: As you examined the research and debates around psychiatric drugs, what felt most important for people to understand when they enter those systems?
DeFehr: People often assume that critique of the mental health field is automatically anti-drug. But I’ve learned from harm reduction work, including Shira Hassan and others. I take a harm reduction and informed choice approach to psychiatric drugs too.
People need access to accurate information about what these substances are, how they may be beneficial for some people, and how they may create harm.
I don’t adopt an anti-drug approach to recreational drugs or prescribed psychiatric drugs. The distinction between those categories is often arbitrary.
We’re talking about psychoactive substances.
For me, Joanna Moncrieff’s models of drug action are essential. They offer a strong account of what psychiatric drugs do and the limits of what we can claim. They help clarify where evidence is lacking. For example, we don’t have adequate evidence that psychiatric drugs specifically target an underlying pathology in the way many people assume.
Instead, psychiatric drugs, as psychoactive substances, produce a characteristic range of effects. Those effects may be helpful for some people, and not for others.
I also think it’s essential people understand tolerance, dependence, and withdrawal. That conversation typically doesn’t happen, at least where I live.
When someone begins a prescription, there often isn’t a conversation about what could happen if they decide to stop. Many people think it’s like stopping a vitamin, or maybe an antibiotic, that you can simply stop whenever you want.
People don’t understand that withdrawal effects can be severe and debilitating. They can also be minimal or non-existent. There’s a range, but people need information.
People also need to understand the potential for harm, not just the potential for benefit. One example, which I find striking, is that the diagnostic manual reserves a full chapter for medication-induced movement disorders caused by neuroleptic drugs, meaning antipsychotics.
These drugs are prescribed increasingly to children to manage conduct, especially in institutional settings like schools.
It’s worth looking at the chapter and listening to people who struggle with things like tardive dyskinesia or akathisia, those torturous sensations that can prevent them from carrying on with their lives.
Karter: As we come toward the end, what can we do instead? You lay out a clear critique of how things are currently framed and practiced. What examples do you see of working outside the dominant system, or changing it from within? And how do people sustain themselves in long-term efforts to repair and reimagine care?
DeFehr: Often we hear, yes, the system has problems. But meanwhile, we need to live with it. We don’t have an alternative.
What I argue is that alternatives have always existed.
First, Indigenous peoples have diverse ways of understanding distress and responding to it around the globe. But there are other communities of practice too.
I highlight dialogic practices, and the importance of the professional adopting a learner’s stance, learning together with people about what they’re facing, walking alongside them, searching for practical understanding, instead of assuming we must be a step ahead.
I don’t meet with people as a practitioner anymore, but I’m thinking of helping work in general. Shared inquiry matters. Mutual learning. Creating conditions for informed choice to the best of our abilities.
Peer-based approaches are essential. Anything that involves communities coming together, solidarity, where people experience the dignity of giving and receiving, and aren’t set up to be recipients only.
For me, an anti-oppressive approach underlies all of it, regardless of the specific practices we draw on. It’s important to understand how systems and structures shape people’s conditions of life, their feelings, and behaviors.
As much as we can, we need to work collectively. That’s my greatest source of hope and strength.
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