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Book Forum   |    
What’s Wrong With the Poor?: Psychiatry, Race, and the War on Poverty

by Mical Raz. Chapel Hill, N.C., University of North Carolina Press, 2013, 264 pp., $39.95.

Reviewed by Sidney H. Hankerson, M.D.
Am J Psychiatry 2014;171:470-471. doi:10.1176/appi.ajp.2014.13121698
View Author and Article Information

The author reports no financial relationships with commercial interests.

Dr. Hankerson is affiliated with the Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York.

Accepted January , 2014.

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As an African American research psychiatrist focused on mental health treatment disparities, I appreciate the complexity of factors that contribute to health inequities. African Americans have higher rates of morbidity and mortality compared with their white counterparts. Racial differences in the utilization and quality of psychiatric services are increasingly attributed to social determinants of health, such as unemployment, institutionalized racism, and under-resourced communities. In the United States, the 1960s is recognized as a decade of sweeping social reforms that were designed to combat poverty and promote racial equality. Persistent racial disparities illustrate how the quest for a “Great Society” remains elusive.

In her new book, What’s Wrong With the Poor?: Psychiatry, Race, and the War on Poverty, Dr. Mical Raz provides a compelling analysis of how mental health experts and policy makers in the 1960s collaborated to participate in President Lyndon Johnson’s War on Poverty. Raz dissects how psychiatric theories of deprivation focused on two overlapping sections of American society: the poor, who had less, and African Americans, who were disproportionately represented among America’s poor and were perceived as having practically nothing.

What’s Wrong With the Poor centers around cultural deprivation theory and its impact on policy. Cultural deprivation focused on what low-income children were perceived to lack in their homes—lack of a “good enough” mother, lack of environmental stimulation, and lack of appropriate nutrition. Mental health experts and politicians widely characterized African Americans as suffering from severe environmental deficits throughout the 1960s. This emphasis on what was missing became the leading rationale for offering social solutions for poor black children.

A critical assessment of cultural deprivation reveals that the theory was based on experiments derived from maternal and sensory deprivation. Respected psychoanalysts, including John Bowlby and Rene Spitz, helped to establish the negative psychological effects of depriving a mother from her child. Sensory deprivation research focused on the psychological effects of environmental restriction and was viewed as complementary to maternal deprivation. In contrast to maternal and sensory deprivation, however, cultural deprivation was neither a distinct scientific field nor based on empirical evidence. Herein lies one of the central tenets of What’s Wrong With the Poor: cultural deprivation theory, which informed the decisions of federal policy makers but lacked empirical validation, was often used interchangeably with race- and class-specific descriptions of maternal and sensory deprivation. Cultural deprivation theory could have been revised by considering alternative sources of environmental and familial nurturance, such as social support through extended kinship networks, which are common among African American families. Raz asserts that cultural deprivation is no longer an accepted term in discussions about mental health and public policy. Thus, it is improbable that future experiments will ever be conducted to rigorously test and potentially revise cultural deprivation theory.

Cultural deprivation theory ultimately provided the conceptual framework for Project Head Start. Since its inception in 1965, Head Start has provided much needed educational services to over one million children annually. However, Raz shows that the initiation of these services reflected deeply rooted stereotypes about what was perceived to be missing in African American homes. In expressing his support of Project Head Start, a pediatrician lamented how “literally thousands of children have never seen a piece of paper, a book, a crayon; they have never heard a song; they have never seen pictures; they have never been stimulated in any way” (pp. 102–103). The views expressed by this pediatrician reflected prevailing perceptions of the time.

Raz highlights how cultural deprivation theory left a mark on psychiatric nosology. In the 1960s, revisions to both ICD and DSM included a category of mental retardation caused by deprivation. Since deprivation was inextricably linked to race, African American children were disproportionately diagnosed with “mild mental retardation.” Disproportionate numbers of African American children were placed in special education classes or in slower educational tracks relative to white children.

As mental health professionals, how do we help the poor? This is a complex problem that will ultimately involve addressing structural inequalities and multiple determinants at the individual, community, and policy levels. In working with individual patients, Raz encourages mental health professionals to avoid labels that pathologize poverty or attribute it to racial defects. She suggests that interventions serving low-income populations would be well suited to focus on empowering rather than “fixing” individuals and drawing on their strengths rather than correcting their deficiencies. Raz concludes her book with a call to more closely examine how psychiatric theories are used to shape public policy. I highly recommend this work for clinicians, mental health advocacy groups, and policy makers.

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