In Zimbabwe, grandmothers take empathy to a whole new level.
Funding for mental health is so scarce in Zimbabwe, and the stresses of poverty are so pervasive, that Dr Dixon Chibanda decided to improvise. When he decided to act, in 2006, he was one of only four practicing psychiatrists in a country of more than fourteen million.
To help fill the void, he set up a program called Friendship Bench. Grandmothers were trained as lay counsellors. They were then sent out to treat tens of thousands of people with common mental health disorders.
It worked. A study found that Friendship Bench was a more effective treatment for depression and anxiety than conventional therapies, at a fraction of the cost. In the 14 years since it began, the Friendship Bench has extended to neighbouring nations and even made headway in New York City.
Depression was (and still is) common in Zimbabweans – especially women – but government-funded mental health care was almost non-existent, accounting for less than 1% of the overall public health budget.
Then there was the problem of reaching affected people. Those living in rural areas had even less access to care than their city-dwelling counterparts.
So Chibanda turned to grandmothers. In Zimbabwe, the term refers to older women who are highly respected within communities and considered keepers of local wisdom – not just those who have grandchildren. Having lived through decades of poverty, gender inequality and civil unrest, they also know a thing or two about dealing with trauma.
Chibanda’s idea was to enlist these women to become what are known as lay health workers – people who are trained and can perform functions related to health care delivery, but do not have a formal certificate or tertiary degree.
To become a Friendship Bench counsellor, grandmothers must be able to read, write and use a phone. After completing a month-long training program delivered by clinicians, they set up shop – or, rather, their bench – in the grounds of a hospital or clinic.
Enlisting older people into community support isn’t a new idea; grandmothers in Zimbabwe have worked as lay health workers since the nation’s independence in the 1980s. For instance, they’ve delivered community health education and home-based care for people living with HIV.
In the Friendship Bench initiative, they now provide basic cognitive behavioural therapy to patients, on a long wooden seat under a tree.
Although it’s packaged as an evidence-based intervention, it’s really all about telling stories.”
“Through those stories, the grandmothers can identify people who need specific psychological intervention. Those stories could be linked to domestic violence, they could be linked to living with HIV, they could be linked to poverty, they could be linked to police brutality. There are so many things happening in Zimbabwe.”
And since Chibanda first envisioned the Friendship Bench, more than 700 trained “ambuya utano”, or community grandmothers, have counselled more than 50,000 clients.
The way the Friendship Bench works is relatively simple. Clients are usually referred from clinics, schools or even the local police station, Chibanda says. “Now with the Friendship Bench having the kind of visibility that it has, we’re getting quite a lot of self-referrals as well.”
On their first visit to a Friendship Bench, potential clients are screened with a questionnaire. Should they score above a cut-off point, they’re invited to stay for their first talk therapy session then and there, which involves three parts.
“The first is called ‘kuvhura pfungwa’, which literally means ‘opening up the mind’,” Chibanda says. “Opening up the mind is creating that space for the person to tell their story, to share their personal story, the challenges that they are facing.”
The session then moves to “kusimudzira” or “uplifting”. “This is a process which involves grandmother feedback by summarising the story,” Chibanda says.
The third component is “kusimbisa”, which means “strengthening”, he adds. “And strengthening is really in essence all about identifying a specific problem that the two of them work on or focus on. It’s all about coming up with a very specific, measurable, achievable and realistic solution.”
These three steps can mean that first session on the Friendship Bench can be quite long – often running for more than an hour. But covering all three components is critical, Chibanda says.
“First, we realise the importance of empowering people the very first day they come. And secondly, sometimes people come from very far away and they can’t come immediately for the second session – it might take them two, three weeks. So if we send them home without a tangible solution, it’s not very helpful.”
The grandmother then follows up via a messaging app or SMS to see how the client is doing, then they chat over the phone to discuss when the client should return for their next chat. And it doesn’t have to be at the Friendship Bench either.
Subsequent sessions are quite flexible, particularly with young people,” Chibanda adds. “We find that a lot of the young people prefer to have what we call ‘walking sessions’. So the first session is on the bench, and for subsequent sessions they’ll prefer to go for a walk with the grandmother or go and sit somewhere where they feel a lot more comfortable.”
If at any point the grandmother thinks they can’t provide the support the client needs, they refer them to a professional.
After a few talk-therapy sessions with their community grandmother over around six weeks, clients are then introduced to a group called “circle kubatana tose” (meaning “holding hands together”), where they receive longer-term support from peers who have also been through Friendship Bench sessions.
Coming to America
The Friendship Bench’s benefits are backed by research. A randomised controlled trial, published in 2016, found individuals with common mental health disorders who took part in the Friendship Bench program had improved symptoms after six months compared to those who went down the standard route of care.
“We thought my goodness, all this work that these grandmothers are doing, this must be stressful for them – they must be burnt out,” Chibanda says.
“But one of my colleagues carried out an extensive study as part of her PhD to look into how working on the Friendship Bench affected grandmothers. The surprising thing is that when we compared grandmothers working on the Friendship Bench to those grandmothers who are not working on the Friendship Bench, we found extremely low rates of common mental disorders like depression, anxiety, and PTSD.”
Working on the Friendship Bench also empowered grandmothers, he adds, not only because they had the skills to support others, but also to help themselves and their immediate family.
The economic impact, too, is significant – especially in nations where mental health funding is tight at the best of times. Not only is the Friendship Bench cheap to run, but treating depression and anxiety in the population has economic benefits as people return to work and school. Indeed, the World Health Organization estimated a US$4 return for each dollar invested in treating depression and anxiety.
To maximise this impact, the Friendship Bench has scaled up – not just within Zimbabwe, but throughout the African continent. There are Friendship Benches in Malawi, Zanzibar and Kenya, Chibanda says, and Liberia and Rwanda are next on the list.
“We are running in New York City in the Bronx as well, and it’s doing very well,” he adds.
While the Big Apple may seem a world away from Harare, they share certain features: homelessness and poverty alongside high rates of drug abuse, HIV and mental health disorders. The “user pays” American healthcare system also means many families can’t access psychiatric services.
Services such as the Friendship Bench will be more critical in the coming years. Mental health needs are forecast to rise and the number of people aged over 65 by 2050 will top 1.5 billion. Can one be used to help the other?
Chibanda thinks so:
Imagine if we could create a global network of trained grandmothers giving mental health support on Friendship Benches in every city in the world?”
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Article by Bel Smith
Photo credit: Photo supplied