2020 vision

Abstract

Although racial inequities in mental health and mental health care have been discussed for decades, inequities persist and little is known about how organizations are attempting to rectify these inequities. Furthermore, the dual crises that were highlighted in the year 2020 (i.e., COVID-19 and police brutality against Black individuals) put a spotlight on health, mental health, and systemic racism, yet it is unclear whether these socio-historic events impacted activities to improve racial equity. This dissertation explores if and how state health and mental health authorities (SH/MHAs) strive to improve racial equity in mental health care in the year 2020. More specifically, this dissertation examines the strategies states use to try and reduce racial inequities in mental health care as well as the barriers and facilitators for developing and implementing these strategies. SH/MHA staff in 47 states across the country completed a brief survey on whether racial equity interventions in mental health care were occurring in their state and, if so, who I should speak with to learn more. Then, 49 in-depth, qualitative interviews with 58 SH/MHA employees across 31 states were conducted, coded, and analyzed for patterns and themes. This dissertation describes the results in three discrete articles. Although there is a growing body of literature that recommends strategies for improving racial equity in organizations and populations, not much is known about how racial equity goals are operationalized in actuality. The first article describes six SH/MHA strategies for improving racial equity in mental health care that were occurring fairly homogeneously across the country and were perceived to be more widely utilized in response to the dual crises. I detail particular tactics within each strategy, the perceived benefits and limitations of the strategies, and how the strategies relate to the socio-historic context. I argue that strategies bifurcate into development activities, which are activities creating higher-quality racial equity plans, and equity-advancing activities, which are actions that may directly impact racial equity. This small distinction may have important implications for the success of reform activities to improve racial equity, both in mental health care and beyond. Crisis can provide opportunities for the public sector to implement equity-promoting improvements in health and social welfare, yet the mechanisms that link crisis to equity efforts remain underexplored. The second article examines how participants felt the dual crises impacted common organizational barriers and facilitators to racial equity change. Building on the agenda-setting literature, the findings support previous claims that focusing events promote buy-in for policy reform, while also creating opportunities for policies built predominantly from preexisting ideas. However, I argue that a crisis may also overcome conventional instrumental and practical resource-related impediments to change, such as a lack of funds, inadequate data, or weak partnerships/community engagement. This contributes to our knowledge of how crises create potential for social change. The sociology of race scholarship describes equity change failures and performative racial equity work but seldom examines the individuals making genuine antiracism attempts from within the walls of power. The third article investigates how SH/MHA staff understand and approach racial equity in mental health care when faced with newfound support for equity reform as a result of the dual crises. Findings show SH/MHA champions - especially people of color and staff in leadership or racial equity-focused roles - had a robust conceptualization of racial (in)equity as well as autonomous motivation and emotional investment in racial equity work. They took advantage of a perceived opportunity to further racial equity efforts in their organizations. This clarifies the role of racial equity champions within racialized organizations while speaking more broadly to the relationship between structure and agency in racial equity change. --Author's abstract