Founder and CEO, Friendship Benches
Fellow project website: www.friendshipbenchzimbabwe.org
Dixon brought mental health care to all with a single idea. Elderly women (“grannies”) with several weeks’ training welcome those suffering from depression and related mental health issues to join them on a “Friendship Bench”. They listen to their guests and then help them begin problem-solving. Eighty-six percent of the half-million Zimbabweans who have come to the grannies see depression and ideas of suicide decline. Dixon’s Friendship Benches have spread widely – – from New York to World Cup soccer.
Dixon Chibanda is shifting norms around mental well-being by bringing mental health services closer to the people. Through Friendship Bench, he is combating both lack of access and social stigma with an evidence-based model that trains and deploys lay health workers, particularly grandmothers (understood in the local context as elderly women regardless of familial relationship), in basic counseling techniques that take into consideration the cultural context. Unlike many mental health professionals in Africa and elsewhere, Dixon has embraced local traditions and cultural norms and integrated them into Friendship Bench’s approach, which is rooted in understanding and that addresses psychological distress in local languages and cultural contexts. Prospective patients who come to primary care facilities with a range of symptoms (both physical and psychological) are screened with a questionnaire in local languages. Individuals who score above a certain threshold for indicators of depression and anxiety are referred to sit with a grandmother on the Friendship Bench (a wooden bench just outside the health care center) for up to six sessions. In this way, Friendship Bench provides culturally appropriate and culturally sensitive mental health support.
Without the Friendship Bench, Zimbabweans would have virtually no mental health care, except for those who can afford the few private doctors. - The New York Times
Research shows that these services have a measurable impact on patients within the first one to two sessions. There is also a positive impact for the elderly lay health workers, for whom this work provides a strong sense of purpose and a way to contribute to society. Dixon’s solution harnesses the power of community support and intergenerational relationships to build an ecosystem of care in a resource-strapped environment. Much of Friendship Bench’s success arises from their lay health workers, particularly the grandmothers, who are rooted in local culture, are respected for their wisdom, and who create a familiar and safe environment far removed from the intimidating clinical atmosphere of a mental health facility. In the first iteration of Friendship Bench, it was called the mental health bench, and no one came, so it evolved to be Friendship Bench which was seen as a friendly place. To date over 500,000 clients have been seen on the bench and with an 86% reduction in depression and suicide ideation among people referred to the bench.
Zimbabwe has been seriously impacted by socioeconomic hardship. An estimated 70% of the population is living below the poverty line, and 34% are living in extreme poverty. Shortages in fuel, electricity, clean water, and climate-related events have drastically impacted the agriculture sector and inflation rates in recent years. The economy has been in decline for several years and the health care system – which was once one of the most robust in the region – has suffered decreased government spending, high workforce emigration and epitomizes this decline. In one high-profile case in 2018, a Zimbabwean businessperson had to provide stipends to nurses and other healthcare professionals to persuade them to stay on the job following months of protesting poor working conditions and what they described as “slave” wages (less than $200 per month). In 2021 alone Zimbabwe lost 2,000 healthcare professionals, according to state media.
[It is a] vehicle for promoting mental health, from park
benches to football stadiums. The Friendship Benches project is a reminder of how the simple act of sitting down to talk can make a huge difference to mental health. - Dr. Tedros Adhanom Ghebreyesus, WHO Director-General
This bleak economic outlook has had a devastating impact on mental well-being. Substance abuse is high and 45 percent of women report being victims of intimate partner violence according to Zimbabwe Demographic and Health Survey of 2015. This means the already over-burdened public health infrastructure cannot cope with such a large burden of mental health and the authorities lack the monetary, staff, and facility resources to tackle the challenge.
As a result, Zimbabwe has high suicide rates according to the World Health Organization data, especially among young adults at tertiary institutions. An estimated 30% of primary care patients have common mental health disorders, yet even within primary care in Zimbabwe there is a lack of access to mental health care. There are only twelve certified psychiatrists in the country and very few psychologists serving a population of approximately 16 million.
The issue with such a large population with a pervasive presence of mental health issues is that clinical psycho-logical methods simply cannot be scaled up to match the growing need, especially with the lack of professional training and knowledge. Moreover, many mental health treatment approaches are not compatible with local cultural practices as they are seen as Western while most mental illnesses are attributed to spiritual affliction, witchcraft, or vengeful spirits. As a result, there is a stigma associated with mental health, and treatment is often sought from traditional healers, therefore, reducing the success rates of clinical therapy or medication. When accessible, people are reluctant to use formal health services for their mental health care, due to high rates of stigma (at a personal and societal level).
At a global level, the problem is equally pervasive. According to the organization United for Global Mental Health, mental ill health costs the world a staggering $2.5 trillion, but that figure could be cut down to a quarter of what it is today simply by making sure that everyone everywhere has someone to turn to. In the rest of Africa, the picture is not vastly different. Mental disorders are escalating amid the coronavirus pandemic lockdowns that have slowed down economic growth leaving many unemployed and uncertain about the future. Investment in public health for mental illness is extremely low with most countries investing less than one percent of health budgets towards mental health. According to the World Economic Forum, an estimated 100 million people in Africa suffer from clinical depression, including 66 million women. The World Bank considers it “the greatest thief of productive economic life.”
The Friendship Bench model is built on the premise that with training, encouragement, development, and ongoing support, lay health workers, especially older women, can become the frontline health workers to deliver culturally appropriate mental health services transforming well-being in underserved communities. A key conceptual framework of Dixon and Friendship Bench is its focus on the cultural context and cultural beliefs around mental health, especially the social determinants of mental health, such as housing, family relationships, illness, and socioeconomic hardship.
Friendship Bench’s approach has attracted a significant amount of rigorous research documenting its success as an evidence-based solution for depression and anxiety. Dixon’s background as a psychiatrist and a public health expert taught him the importance of clinical validation, and his networks have helped Friendship Bench gain access to skilled researchers and reviewers. The first publication to review the effectiveness of this model was the Journal of the American Medical Association. Dixon made the deliberate choice to focus on publication in a journal that does not solely focus on mental health, but health more broadly, to encourage primary care medical clinics to take up this solution, rather than limiting it to a mental health space. A study on the effectiveness of Friendship Bench was published in the Journal of American Medical Association in December 2016. The study found that patients with depression or anxiety who received problem-solving therapy through the Friendship Bench were more than three times less likely to have symptoms of depression after six months, compared to patients who received standard care. They were also four times less likely to have anxiety symptoms and five times less likely to have suicidal thoughts than the control group after follow-up.
Friendship Bench’s reliance on elderly women (grannies) and other persons as lay counselors linked to primary health facilities addresses the crisis of chronic understaffing at government health facilities. These lay counselors engage in conversation with their clients, providing cognitive-behavioral therapy tools contextualized to local languages and norms, to individuals suffering from common mental health challenges such as depression and anxiety. Grannies are trusted messengers who share the cultural background of the people served by this solution and therefore lower the barrier for entry, making it easier for patients to take up new ideas. The emphasis of the interaction on the bench is less on the medical diagnosis but on providing a safe space for a patient to tell their story. Storytelling in mental health helps people feel less alone, and it cultivates empathy and compassion.
The assessment tool used by primary care health clinics to determine who is referred to Friendship Bench is locally validated and designed for the communities it serves. Grannies (lay health workers or LHWs) who sit on the friendship bench and see patients are trained to provide six counseling sessions completed within four to six weeks. LHWs ask questions that encourage clients “kuvhura pfungwa” to open their minds, identify a problem, and proactively tackle it. Following problem identification and exploration, LHWs guide their clients on an action plan toward a feasible solution. Following the six sessions with the grannies, patients are invited to an optional additional 6-session peer-led group support program.
The peer-led support group is known as Circle Kubatana Tose (CKT), meaning ‘holding hands together.’ In these groups, clients are connected to other Friendship Bench clients who received counseling sessions and became empowered to solve their own problems with others that they can relate. Through talk therapy clients have learned about the benefit of empathic listening and can co-create a safe space to talk to and be heard by their peers.
These support groups contribute to clients’ sense of belonging and reduce the stigma surrounding mental health and sharing of personal issues. As an extension of problem-solving skills learned on the bench, these groups are engaged in revenue-generating opportunities, which is vital in a country with high levels of unemployment and poverty, factors that contribute to socio-economic distress. For instance, clients can participate in the creation and sale of large, colorful shoulder bags made from recycled plastic (known as “zee bags”).
To date over 1,400 community health workers have been trained to provide psychosocial support to people in need in their communities. Friendship Bench has seen over 150,000 patients served and according to results of a randomized clinical trial published in the Journal of Medicine, clients seen on the Friendship Bench demonstrated a 60% improvement in quality of life and an 80% reduction in depression and suicidal ideation. As a result of its demonstrated effectiveness, it has been adopted by the government as part of the national mental health strategy. Scaling its implementation across all primary healthcare facilities in Zimbabwe is a priority for Friend-ship Bench.
Simultaneous to the roll-out of Friendship Bench throughout Zimbabwe, Dixon and his team have been undertaking pilots globally. Drawing on his affiliations with the London School of Hygiene and Tropical Medicine and the African Mental Health Research Initiative (AMARI), Friendship Bench is tapping into a network of professionals undertaking core research for its expansion and building a network of adopters of the model throughout Africa and globally. To date, the initiative has spread to six countries including Kenya, Malawi, Tanzania, the U.S., and Vietnam. The WHO Mental Health Gap Action Programme (mhGAP) has adopted it as a blueprint for how to integrate mental health into primary health care. Friendship Bench has developed a five-phase implementation model they use to establish the suitability of the model for potential partners and develop a rollout plan. Within each phase exists various stages which get worked in collaboration with potential partners; every delivery will be unique to each community. The phases are as follows:
1. Establishing Suitability
2. Theory of Change Workshop
3. Partner Preparation
4. Training of Trainers and Training of CHW
5. Monitoring & Evaluation and Tech & Online Support
This makes it easier to scale the Friendship Bench into other countries. The strategy for growth involves providing technical assistance to other organizations and health ministries that would like to implement the Friendship Bench model.
‘Friendship Bench’ is a novel way of providing free mental health support to poor compatriots by enlisting the help of older health workers. The Zimbabwean project is temporarily setting up shop at the FIFA World Cup in Qatar late this month to highlight the importance of health therapy. - AFP
In addition to the Friendship Benches at primary health care centers, Friendship Bench has developed peer counseling services at universities and offers online counseling services delivered by Friendship Bench-trained mental health supporters. Online sessions are held on WhatsApp calls or chats. They include screening for depression and anxiety as well as problem-solving talk therapy-based support. Sessions last 30-60 minutes (the first session is usually the longest). This is designed for people struggling with mild-moderate depression, anxiety, as well as substance misuse, suicide ideation, emotional distress, relationship difficulties, or people who have a poor quality of life due to the emotional distress brought on by chronic medical illnesses such as cancer, diabetes, or HIV/AIDS. The online platform has made it gender inclusive in that men and women have differences in health-seeking behaviors and preliminary data shows more men are active on the online platform than women.
Dixon’s ability to spread the Friendship Bench model is significantly helped by his professional ties to leading universities and research institutions in Zimbabwe, all of Africa, and the U.K. This brings in research on the science and the efficacy of the approach – and therefore credibility and connection. Dixon has deliberately used Friendship Bench to nest Ph.D. students to carry out rigorous research on its work and later to spread the idea. This also helps him recruit new staff. The current research lead, for instance, is a former Ph.D. student, and the Youth-Friendship Bench lead is another former student. Dixon’s university and research ties also provide an opportunity for the wider team to interact with other researchers including international collaborating partners and develop an interest in mental health among medical doctors and researchers.
Dixon Chibanda was born in Zimbabwe during the liberation struggle for independence. Part of his early years was spent in Zambia as his parents were in exile. For the most part, he had a normal childhood, but two traumatic events would unconsciously shape his path to working in mental health. The first was his parents’ divorce when he was 12 years old which he took very badly. The second was finding himself being the only boy of color in an elite boy’s school in Harare, Zimbabwe shortly after independence from colonial rule. The racism he faced from the teachers and the students was unimaginable. According to Dixon, no one wanted to stand next to him or speak to him, and when his father complained things only become worse, and eventually, he was transferred to a more diverse school. He went to Comenius University in Bratislava, Slovakia and again the racism was rife, which strongly impacted him.
Dixon always knew he wanted to become a doctor, but dermatology and pediatrics were his original interests. While in medical school in the Czech Republic, however, one of his classmates died by suicide and this tragedy had a profound impact on him, which led him to choose psychiatry.
Another seminal moment influenced Dixon to understand the nexus between culture and medicine. Between 2003 and 2005 Dixon spent time in Ouidah, Benin as a Junior Consultant for the World Health Organization trying to formulate policies around the rights of people with mental health issues. Outside their compound was a Voodoo priestess and after many nights of hearing the drumming from the compound Dixon’s curiosity led him to the compound to observe what was going on. As a psychiatrist he could see that many of the people brought to the priestess had clear mental health challenges and that the way the priestess related to the clients and understood the deep cultural idioms of mental distress helped to calm clients and make them feel understood, and thus more open to treatment. He also observed a deep disconnect between science and the culture of people living with mental illness. Unsure how he would use this knowledge he returned to Zimbabwe.
In 2005, back in Zimbabwe, two tragic events occurred that led Dixon on a path to urgently find solutions to bridge the treatment gap of mental well-being. One of his patients died by suicide in a rural village because the family did not have money for bus fare to bring her to treatment in the city. The second was the mass displacement of the urban poor in Harare following a brutal government-led campaign, Operation Murambatsvina (“remove the filth”), which saw the destruction of informal settlements around the capital city leaving 700,000 people homeless and in deep mental distress. Dixon was the only psychiatrist working in the public sector at the time. He began studying public health to understand better the social determinants of mental health and to look for solutions to address access to mental health in the poorly resourced public sector. Informed by the lessons in Ouidah of embracing cultural wisdom he started training grandmothers to provide psychosocial support and thus the Friendship Bench was born.
Dixon completed his medical studies in 1993 at Comenius University in Bratislava, Czech Republic. He also holds master’s degrees in Psychiatry and Epidemiology from the University of Zimbabwe and a Ph.D. in Psychiatry from the University of Cape Town. After graduating from the University of Zimbabwe, he worked as a consultant for the World Health Organization.