Dr Umar Toseeb Hello, welcome to the Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Umar Toseeb, Professor of Psychology. My research focuses on special educational needs and mental health in childhood and adolescence. All listeners to this, and indeed any of ACAMH’s podcasts, are eligible for a free CPD certificate. Do please visit acamhlearn.org for details of this, together with information on how you can access hundreds of hours of free talks, lectures, interviews, all of which you can also get free CPD certificates for. The web address is acamhlearn.org, that’s a-c-a-m-h-l-e-a-r-n.org. Today, I’ll be speaking to Dr Kenisha Jackson, Consultant, advising professional networks supporting children and families in health and education. Kenisha is also a Child and Adolescent Psychoanalytic Psychotherapist, a Minister of Faith, SEND Lead Governor, Healthy Minds Teacher, Founder of KEW Education and Therapy. The focus of today’s podcast will be access to and experiences of mental healthcare for marginalized children. Kenisha, thank you so much for joining me. Dr Kenisha Jackson Thank you for having me. It’s great to be here. Dr Umar Toseeb That’s a lot of things that you do. Dr Kenisha Jackson Yes, I wear many hats, but I think the great thing about it now is that they all weave one into the other, and the primary focus is always about children and families, ensuring that they get the best access and help and support that they need. Dr Umar Toseeb Let’s talk about one of those hats that you wear. What is psychoanalytic psychotherapy? And as in, like, I think listeners might be familiar with CBT, ‘cause I think that’s quite… Dr Kenisha Jackson Yes. Dr Umar Toseeb …a dominant approach in the UK healthcare system anyway. Dr Kenisha Jackson Sure. So, psychoanalytic psychotherapy, we primarily are focused with the unconscious, what is happening in the internal world? What is happening for that child? These are the things that we’re thinking about as Psychoanalytic Psychotherapists. So, in my line of work and in our training, we work with children nought to – up to the day before their 26th birthday. Dr Umar Toseeb As a person of colour who didn’t necessarily come from an affluent background, what you’re describing, to me, sounds very white, middle class, type approach, and one that people with similar backgrounds to me might not have had the opportunity to access if we were also going through similar problems. Who is the profile of person that comes through your door, and is there a problem with access? Dr Kenisha Jackson It’s a really great question. I think the first thing that jumped out at me when you said it “sounds like a white, middle class type of approach,” I was curious to know more about that. What was it that I said that made you think, ah, I don’t know whether this is for the community that I come from? Was there a particular word or something that, sort of, stood out? Dr Umar Toseeb Well, I think it’s the unconscious bit. I think we mi – I can only speak for my family, it’s what manifests, and then you… Dr Kenisha Jackson Yeah. Dr Umar Toseeb …you speak about what manifests… Dr Kenisha Jackson Sure. Dr Umar Toseeb …rather than what’s going on underneath. I think, in general, access to, based on my understanding, psychoanalytic therapy, is – I wouldn’t expect it to be on the NHS… Dr Kenisha Jackson Hmmm. Dr Umar Toseeb …and then for that, it seems that there’d have to be a certain level of privilege to access. Dr Kenisha Jackson Thank you for the clarification. I guess, first of all, psychotherapy is on the NHS. I’m a Child and Adolescent Psychotherapist, I’m one of the senior Clinicians there. But you’re absolutely right, there are children and families who think this isn’t for me, never heard of it before. Whereas, you may have your – I guess my research shows, historically, it has been quite a white, middle class, type of profession, to train and to become a Psychotherapist, but equally, a white, middle class type of talking therapy, where these parents will know about such service and will request such service. But if you don’t know about something, it might be hard to request it, not just from the parent’s point of view, but also from the referrer, so the GP. Does a GP know about it, does a Schoolteacher know about it, as something that could be recommended to a family when they see a particular type of presentation? But it’s what we consider to be a specialist type of intervention, and it’s usually a long-term intervention. So, they will have an assessment to see whether the child would be suitable to access psychotherapy. Usually we ask that the external factors are quite stabilised, so, you know, they’re at – they’re going to school, their housing situation is stabilised, so they’re not, sort of, moving from borough to borough. Because usually it’s long-term work, so we want you to be stable so that you will be able to access it. It’s a weekly intervention that you would come and you would see a Clinician, and you’ll be able to access intervention through play and drawing and interpreting, and those drawings and the play, or whether it’s an older child who’s able to just sit as an adolescent and engage in talking and discussion of a kind. And it’s child-led, so it’s what the child brings to the space, so they – whatever they want to talk about is what we would engage with. Dr Umar Toseeb I think what you’ve described in terms of the ‘referral pipeline’, for me, it also comes across as, you already need to be in a position of somewhat privilege, because it – to have stable housing, to not be moving around. To not have those external stressors that were potentially causing the mental health difficulties, to be able to engage in various aspects of play, would require you to be of a certain social standing probably, or social stratification, as I said, just because there’s lots of people out there who wouldn’t fit that criteria. Is part of the problem… Dr Kenisha Jackson So… Dr Umar Toseeb …the referral pathway? Dr Kenisha Jackson Sure. I think it’s a fantastic question. You know, often I hear, “Well, actually, maybe the work needs to happen with social care to stabilise all of these things before we can do some work,” and it’s a bit like the chicken and egg, but, actually, it’s all of the instability that’s causing the distress, so how do we get around that? And sometimes what it looks like is actually having Therapists that go into schools. So, in some boroughs there are Psychotherapists who are set up and available in schools, and you find, I guess the research shows, that sometimes that’s the way in for families who wouldn’t ordinarily access psychotherapy, because of stigma, because there’s an idea that, “It’s not for us,” but, actually, school feels like a familiar and a safe space. Also, what I’ve found helpful is sometimes if I’m doing a parent meeting, that I might meet a parent at school, particularly if sometimes English as a second language, and coming to the clinic feels uncomfortable. Who am I going to see? Who am I going to meet? You know, if English is a second language, and there’s a onsite Interpreter. Sometimes those things work very well. So, I’m always keen to think outside of the box with a child and family, to think about, how can we break down the barriers? What does it mean to come to a CAMHS clinic, you know, to meet with a professional, someone who’s got a badge round their neck and it says ‘Doctor’? For some people that feels really, really reassuring, you know, they’re qualified, they know exactly what they’re talking about, and this is who I’m going to see and it’s in a building, and for others, that might feel terrifying. Actually, it feels quite frightening to go to that setting, because for me, in that setting, it was quite difficult. Equally, going in – back into the school setting for some parents is overwhelming. Being invited into schools can stir up so much anxiety. So, for me, it’s about more than what, you know, sort of, meets the eye on the surface, and equipping professionals that would be coming into contact to the – with the children that you described, marginalized communities, to understand, actually, there’s more to this dynamic. It’s not that mum or dad just don’t want to come into school. What else might be getting in the way, and how can we bring our services to the families? Dr Umar Toseeb Thank you, and I suppose, is there value in talking about the demographic of the people who are – have unequal access to psychoanalytic psychotherapy, is it who we would expect, typically, who are marginalized in society? Dr Kenisha Jackson I think – I’ve worked across a number of London boroughs, and actually, each borough has its demographics that access the service. So, I don’t think – whilst my research shows that there absolutely is a underrepresentation of Black children and families accessing mental health services, that the research shows that, it’s undeniable, it’s happening, we know that it’s there, but when I’ve worked in different boroughs, in various NHS Trusts, you will find that there’s a particular cohort of children and families accessing the service. But I think culturally, there is this idea that – and particularly in the Black community, the research shows, “We – well, we don’t talk about our business outside of the family home. Why on earth would we do that? And what’s the point in just talking? I need some practical help.” And understanding that actually in talking and understanding, having a professional who understands your needs means that that professional can also support and advocate for you. So, until those barriers are broken down and people see more people that look like them and sound like them offering the therapy, it will take a while for people to recognise and to see that the service is for them, and it’s not for a particular type of people who look a particular way or sound a particular way. Dr Umar Toseeb Thank you, and we’ve talked a bit about the ‘pipeline of inequality’, and we’ve talked about ‘referrals.’ Is there more you want to say about your work on the audit of referrals within CAMHS? Dr Kenisha Jackson I think when I did the research, there was over 4,000 referrals into the, you know, the CAMHS service at the time. And of those referrals, only 600 of those were from, you know, families who identified as being Black, Black British, Black African Caribbean. And of those only 400 of those were actually – took up the service and engaged in some type of therapy. Whether that was one session or more, the data doesn’t really break it down into those, sort of, finer details. So, the referrals are being made, but only a small number are actually being accepted, and only a small number are actually engaging. So, there’s two things. You talked about ‘referral’ and ‘access.’ You first have to be referred, and then you have to feel safe enough to access the service, so you may be referred but you don’t engage, for one reason or another. Often, we hear that particular groups are ‘hard to reach’, and I often think about, well, it’s the service that perhaps is hard to reach. The research shows that for some families, they were trying to engage with the service for a very, very long time, raising their concerns, speaking to professionals, but it was very, very challenging to actually get into the service. Dr Umar Toseeb What are people’s experiences like once they are in the CAMHS system and taking part in psychoanalytic psychotherapy? And I suppose we could talk about the experiences of parents, children and Therapists. Dr Kenisha Jackson Yeah, I think it’s important to note that therapy is hard work. You know, somebody perhaps might have been waiting for psychotherapy on the waiting list for some time, and once they do get to the top of that waiting list and they are able to access therapy, whether that’s, you know, through the NHS or private practice, but once you get into that therapy room, it’s just like any other relationship. You’re needing to build that therapeutic relationship, and it takes time. And I think particularly with marginalized groups, it’s going to take that bit longer, because there – you know, I guess the research shows that there’s perhaps lots of fear in the system, on both sides. “Who might I meet when I get to this therapy session? Will they understand me?” You know, “How am I going to articulate my worries and concerns?” All of those things, preconceived ideas, stigma, all of that, will need to be broken down before you can build that therapeutic relationship, where they can engage. And it might look like disengagement, it might look like offering an appointment and they don’t turn up or they’d forgot, or they tell you they had to be on the school run. And these reasonings might be genuine, but it’s their way of perhaps managing, actually, I’m not sure whether I want to do this. I’ve not experienced this before. I don’t know what it means to speak to a stranger about things that are happening for me and my family personally. It’s a new experience.” Likewise, children who may have adopted the same view that, “Actually, well, we don’t really talk about that outside of the home, and here I am with somebody who might be expecting me to talk.” And I think what’s also very, very helpful is I think the anxiety level sometimes comes down when children realise, actually, they can come into a room and just play, and there isn’t an expectation to have all the answers, and sit and be able to articulate oneself. It’s not about that, and as they get older, they might decide to sit in a room and just draw, or sometimes there’s periods of silence. What does the silence feel like? Does it feel tense? Is there anxiety, sort of, stirring in me, as the Clinician? Also gives me indication to what might be happening. If I suddenly find that my heartbeat is racing, oh, well, actually, what might be happening for the patient? And we call that ‘transference’, that there are things that we can feel in our bodies that might actually indicate what might be happening for the person sat in front of us in that consulting room. Dr Umar Toseeb I heard the term ‘generational trauma’ used amongst my own community, and I always – well, I hadn’t always, but, like, I – it occurred to me that maybe, at the time, it’s just a my community specific thing. Is it the case that certain marginalized communities have more generational trauma, partly due to, for example, migration and then the higher levels of poverty and different cultural experiences to the dominant culture in the UK? Is generational trauma more of a problem for marginalised communities? Dr Kenisha Jackson Absolutely, I think for the reasons that you mentioned, about ‘migration’. If we think about, for example, the Windrush Generation, from the Commonwealth countries, who at the time, were British citizens and invited to the UK to rebuild after the World War, for example. Came to the UK from those countries and built the NHS, in those roles and in those jobs, and an invitation in to do a piece of work and then realise, actually, we’re not really welcome. And then what does that mean, and what does it feel like? And then having to work really, really hard to build for oneself, but also building up barriers in order to protect oneself from the outside world that didn’t feel safe. And how much of those strategies have been embedded and are still here present with your second and your third generation, who are still using those strategies? Because we hear about the overrepresentation of Black children and families, for example, in inpatient wards, but an underrepresentation of them accessing mental health services at the early stages. You know, Black Caribbean children being five times more likely to be excluded from school, or Black women being four to five times more likely to die during pregnancy or childbirth. Now, these stats, people find it quite shocking, but it’s happening. So, if this is your ordinary day-to-day experience, for example, 19 times more likely to be stopped and searched by the Police, you’re going about your business, but this is your experience that – as a young person, or even a school-age child - you know, we heard about the, sort of, Child Q case where, you know, the Black girl was strip-searched at school, and what that means to have those lived experiences. And even if you haven’t experienced it yourself, you know of somebody in your immediate community who may have experienced this, or you’ve watched it on TV, or you’ve seen on social media, there’s trauma there, you know. You’re still experiencing it, because, actually, that person looks and sounds like me, so that could be my mother, brother, sister, auntie, uncle, who could have had that experience, and is the outside world safe? And if the outside world doesn’t feel safe, I need to put things in place to safeguard myself. And in order to access therapy, one will need to be vulnerable. How can you be vulnerable if you don’t feel safe? When I talk about a lot of things needing to be worked through and broken down before the therapeutic relationship can begin, those are the things I’m talking about for us or against us. I guess, in my experience, sometimes it takes a bit longer, but sometimes people come in and they can just sense that there’s somebody who genuinely cares, genuinely wants to know their story, and is there to help and to pull things together when there’s been a long history of hardship and struggle. And actually, there are services out there that you can access, and I might be that voice to advocate on behalf of. Dr Umar Toseeb And you’ve talked a bit about ‘society’ there. If we’ve got lots of problems in society and the people who are marginalized are marginalized by wider societal problems, what can therapy do in the context of all of that? As in, if that doesn’t change, what is the value of therapy, even after nothing else is changing, assuming nothing else is changing? Dr Kenisha Jackson You know, I can invite somebody into my consulting room to, you know, sit with me for 50 minutes, but if the minute they leave, they go back into, as you said, the community where they’re immediately stopped and searched, or they go back into school where the school system doesn’t quite understand their communications, or even the home environment, and that’s why we like to work with parents, as well, that what’s being done in the therapy room isn’t being undone outside of the therapy room. So, that’s why lots of my work has been developed to support the network, so that’s the parents, but also the wider network, to help the police understand, actually, when you stop a young person, what else might be happening? What else might be happening in that classroom where a child might lash out, for example? What else might be happening, and how do they experience being restrained? So, lots of my work is – and I’m extremely passionate about working with a network, to understand who do I have in my classroom? Who is sat in that room? Who am I seeing? Irrespective of how they present. It makes it difficult to have those communications when the expectations are so high, and perhaps your white counterpart in that classroom is having a completely different experience. You know, there’s the same class incident, but the sanction is different. You know, it might be an internal exclusion, it might be an external exclusion, you know, whereas, your white counterparts, perhaps are being seen differently and dealt with differently. Likewise, their parents, perhaps who are able to ask the questions because they have a better understanding of the British education system, so they can say, “Hold on, actually, I think my son or daughter needs this.” If you don’t know it exists, how can you ask for it? There’s so much to be done externally. Yes, as I said, I can do – come into my consulting room, one-on-one, with the child or with the family, but how can we support the network? And when I work closely with the network, I see very difficult situations start to shift. Dr Umar Toseeb And you talked a bit about this earlier, and the issue of ‘representation’. How important is representation in therapy? And that’s in the two parts of that question. The first is, the Therapist, and then the second is, whether the therapy has been designed and developed with the needs of a particular population in mind. How important are those things in therapy, and to what extent are they happening already? Dr Kenisha Jackson Well, there’s lots of talk about widening access to, in particular train to become a, you know, Psychoanalytic Psychotherapist. You know, for the NHS, it’s funded, the training is funded, so there is lots of emphasis on widening the access, but I still have some questions and queries about those who are teaching on those courses. How equipped are they to train the people that they are trying to engage on these trainings so they can become qualified Therapists? They too need a level of training to be able to engage. In order to become a Psychoanalytic Therapist, you have to undergo your own therapy. So, on my particular training, the personal therapy requirement was for four times a week for four to five years, so it’s a lot of therapy. And right at the beginning, I was thinking, what am I going to talk about? You know, but you’d be surprised. There’s an invitation in, but how equipped is the profession to receive potential students from marginalized communities? That’s the first question. So, they go through the training, they come out the other end, and what we want to do is equip Therapists to be culturally competent and to be culturally aware and culturally sensitive to what families are bringing. And that requires careful listening, and, also, having some support from your colleagues, and so it is about shared learning, I think is important, sharing good practice is also important, and representation, as I said, it’s key. I went to a school to do a presentation and there were very few Black children in the school setting, but one of the things that – when it was time for Q&A, they, sort of, came up to me, and “Maybe you could come and be our – replace our Counsellor.” So, immediately, they saw somebody that looked like them, and I think that makes all the difference. If they can see somebody that looks like them, it might mean that they have an understanding. But likewise, I think there’s also an element of not imagining – and I’m always careful of this, that I know your story because we look alike or sound alike. Actually, your story is individual to you. So, not every Black family that walks through the door I’m going to know and understand their story. Their story is their story, but what I can do is invite you to tell me your story and not assume that I already know it. Likewise, for any other Clinician, not to assume that they know somebody’s story because of the person that they saw last week and they have a similar background, or they share the same skin colour or language. That actually, this is an individual with their own story, with their own journey, and how can we be interested in the person who’s in front of us without making assumptions and letting go of those stereotypes and preconceived ideas? Ask the question. People want you to ask, “Well, tell me about your background. Tell me about what brought you to the UK,” if they were not born here. Invite people to tell their story and often, that’s missing from the information. We don’t know where the family come from. What’s the ethnic background? How did they come to the UK? Whether it’s them or their parents or their parents’ parents, you know, what happened? What’s the journey, where are they coming from, and what does it mean to be in the UK now? How did you get here? Because that’s so important. Just as we ask, “Well, what was the journey like here to the clinic?” I want to know, “What’s your journey here to UK?” for example. Also, I – you know, I mentioned before about, “Well, what’s your lived experience of accessing services?” Because if it’s been a challenging experience, then coming to see me also might feel challenging. “Are you going to judge me – are” – often people say, “Well, haven’t you got the notes?” And I say, “Yes, but I like to hear from you,” you know. Because the notes perhaps on the system is somebody else’s interpretation of what was shared in the last session. I want to hear from the family what their experience has been, what their hopes are, what’s the presenting issues now? So, I think it’s being open, being curious, being interested, and not assuming that we have all the answers. Something I always say to the families that I meet, “You are the expert on your child. I might be the professional, but you know them best. So, I invite you to tell me all about your experience as a family, and then I can use my professional skills and expertise to think about what you’ve shared with me.” It’s about thinking together. It’s a co-production, if you like. Dr Umar Toseeb Thank you, it’s a wide-ranging discussion. I have so many more questions, but we’re going to have to wrap it up. What’s your take-home message for our listeners? Dr Kenisha Jackson I think the take-home message for me would be, therapy is not exclusive to any one group. Particularly psychotherapy is for everyone, and I think, most importantly, you don’t have to come with all the answers. The professionals are there to help, and just start at the beginning, one step at a time. Dr Umar Toseeb Thank you. Absolutely really enjoyed that. Thank you so much. Dr Kenisha Jackson Thank you for the invitation, once again. Dr Umar Toseeb As always, please visit the ACAMH website, www.acamh.org, and on X, @ACAMH, where you can find out more about Dr Jackson. ACAMH is spelt A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with your friends and colleagues.