Seen one day crying and alone at a community shopping center, someone referred her to a local health clinic. In years past, there may have been little that primary care doctors there could do for a woman overwhelmed with suicidal thoughts. But these days, she was referred to a wooden park bench outside the clinic, where an older woman would sit with her and talk through her problems.
On any given afternoon in a discreet area outside health clinics in the capital of Harare, and surrounding cities, an elder woman can be found on a bench listening intently to another person’s stories.
She’s affectionately called a “grandmother,” an appropriate term for her role offering comfort, encouragement and a ready ear. But she’s no one’s grandmother, at least not of the people who sit with her on the bench. Rather, she’s one of 300 older Zimbabwean women who have been trained to administer therapy-like services to thousands in a country where access to care is devastatingly scarce and the mental health stigma is strong.
During their six sessions, the grandmother found Netsai temporary housing. Then the grandmother reached out to Netsai’s husband to invite him to joint counseling. After several meetings, he asked his wife to move back home with their daughter, Chibanda said.
The idea for the unorthodox treatment model came to Chibanda, one of only 13 psychiatrists in a nation of more than 14 million, when he was working on his master’s degree in public health and did a field study on the prevalence of common mental health disorders such as depression and anxiety in Zimbabwe. He found that upward of 25 percent of people — a number comparable to diagnosable mental illness in the United States — were struggling with some kind of psychological distress. And, as in America, the rate of suicides, particularly among men, has been rising.
So, how to get help to all the people who needed it when there were few financial, technical or material resources? And how to convince people to reach out when their culture made them reluctant to admit their emotional pain for fear of seeming weak or even possessed?
To address both, Chibanda stripped mental health care down to basic human connection. He removed the medical and technical elements that made seeking treatment intimidating, and developed a simple solution to enlist the help of lay health workers who could take on matriarchal roles. He first called the meeting spots “mental health benches,” but that was too stigmatizing, so he gave them a more inviting name: “Friendship Benches.”
The grandmothers are trained in what is essentially the Western model of cognitive behavioral therapy, but they use indigenous terms that their “patients” can more easily relate to. There’s not even a word for depression in Zimbabwe, that’s too clinical. Instead, people call what they’re feeling, “kufungisisa” or, “thinking too much.”
Using the native Shona language, Chibanda teaches the grandmothers how to administer three stages of talk therapy. The first is “kuvhura pfungwa,” which translates to “opening up the mind,” a method of encouraging them to identify their problems and feelings. Then they move on to “kusimudzira, which means “uplifting the individual,” where the grandmother works with the person on problem-solving. And finally, “kusimbisa,” which translates to “strengthening,” and is a way for the grandmother to give the person coping tools they can use again and again.
In addition to Chibanda, the program is overseen by a team of psychology professionals, including a senior psychologist. The grandmothers are also trained to recognize “red flags,” and determine whether the person needs more advanced medical care.
“This intervention is problem-solving therapy, in which the patient identifies a problem (eg, unemployment) rather than a diagnosis or symptom, and has been shown to be feasible and acceptable in this resource-poor setting,” Chibanda wrote in a co-authored clinical paper about the program published in the Journal of the American Medical Association in December 2016. “The psychological approach of problem-solving therapy works through enabling a more positive orientation toward resolving problems and empowering people to have a sense of greater coping and control over their lives.”
Chibanda’s program has reached 30,000 Zimbabweans, and his clinical trials have shown a significant decrease in suicidal thoughts and depressive symptoms after the people meet with the grandmothers, he said. And the treatment is continuous. After the patients have done several sessions with the grandmothers, they are often referred to peer support groups where they might learn a skill together, like how to weave bags with recycled plastic.
“It’s a powerful way of keeping that link with the grandmothers,” Chibanda said in an interview. “Human contact, which is often overlooked when we prescribe medication, can be equally as effective for mild to moderate depression. I fell in love with the whole idea of sitting down with people and being able to uplift a person, talk them through and out of depression through all of these evidence-based practices.”
In Zimbabwe, the ratio of traditional mental health professionals to the population in need is an extreme example of a global problem affecting both the developing and developed world. In countries big and small, rich and poor, the need for mental health services outpaces the resources available.
In the United States, the situation isn’t quite as dire, but the issue is just as pressing. One study found that 55 percent of counties in the United States do not have any psychiatrists and 77 percent are underserved, according to a report released last month by the National Council for Behavioral Health. And in those areas where there are enough psychiatrists, it has become increasingly common for the doctors to shift to a cash-only practice, making psychiatry a medical specialty out of reach for Americans who can’t afford the cost. Then there are long wait times to schedule an appointment and rushed visits that dilute the quality of care. By 2025, it’s estimated that the demand for psychiatry will surpass the amount of doctors available by 25 percent, according to the report.
That data is underscored by an analysis released this week by researchers at New York University’s Langone Medical Center, who found an uptick in Americans with serious psychological distress, but also an increase in difficulty accessing care.
Research has shown that social support methods of care are effective to treat mental illness. Community integration and acceptance can play a significant role in serving all populations from those with the most serious mental health disorders to more common conditions while isolation and feeling as though there is no one who understands is known to exacerbate symptoms.
Which is why Chibanda believes his friendship benches could be a model used around the world in any community to reduce the gap where access to care is limited.
“The problems are not unique to Zimbabwe,” Chibanda said. “You could plug it into New York and get the same results.”