The two most common mental health issues, depression and anxiety, are also the leading cause of disability globally. The economic impact and societal ramifications are increasingly being recognised and a cultural and policy shift in the way mental health disorders are perceived and tackled is already underway. However, much remains to be done to address the stark discrepancies between the availability of treatment in different parts of the world. Dixon Chibanda is Professor of Psychiatry and Public Health at the…
Dixon Chibanda puts grandmothers on benches, literally. As the Professor of Psychiatry and Public Health at the University of Zimbabwe, he is a leading academic, practitioner and advocate for cutting-edge public mental health initiatives. His research focuses on developing sustainable community-based mental health programs such as the Friendship Bench, which trains Zimbabwean grandmothers as lay health workers to deliver counselling from a wooden bench. Ahead of Falling Walls 2019, we talked to Dixon about his plans to break the walls of mental health.
Falling Walls: You are probably most know for a mental health initiative called The Friendship Bench. What is it all about?
Dixon Chibanda: It started in 2005. It wasn’t planned. The government in Zimbabwe embarked on a clean-up operation, which was politically motivated and left several hundred thousand people homeless and had a huge psychological impact. At the time I was the only psychiatrist working in the public health space. So I was instructed to do something about it. But I could not work with any of the doctors or nurses, because they were too busy. So I got assigned 14 grandmothers, which was very depressing at first. But I decided to sit down with them and figure out how to help the community. At around the same time, I lost a patient of mine called Erica. She took her own life and one of the reason was because she couldn’t come to see me at the hospital because she didn’t have enough money for the bus fare. That was the realization for me for the need to take mental health to the community instead of having people coming to the clinic. So I came up with the idea for a Friendship Bench: A bench, where trained grandmothers sit down with members of their community and talk about their mental health.
Falling Walls: Can you run me through a session on a Friendship Bench?
Chibanda: First of all, people have to be referred to the bench. When we started, the benches were linked to primary health care centres and patients were referred by the nurses and doctors. As it began to grow, people were referred from the community, from the school, the police station, from everywhere. We had to design a system to detect people that need help the most. When you sit down with a grandmother, they first invite you to share your story. As you talk about whatever it is, they are screening you according to a validated screening tool. They ask questions likes: How is your sleep? Have you found yourself very tearful? Did you have thoughts of ending your life? Depending on how many Yes-Responses they get, the grandmothers know how to structure the session, how to select one problem that bothers the patients the most and how to find achievable and timely solutions.
Falling Walls: What happens if a patients has a severe problem that need medical attention?
Chibanda: If you get a red flag, i.e. if someone responds yes to a question about suicide, then you ask more questions. If the second round still shows a red flag, this person is then referred to the peer supervisor, a grandmother who has been working for a longer time. If that grandmother cannot help, the person is transferred to the clinical psychologist or psychiatrist. In some cases, you also need medication that the grandmothers obviously cannot provide. But keep in mind that the percentage of all patients that are transferred to the next level is less than 5%. The majority of cases who deal with anxiety or depression can be treated by the grandmothers on the bench.
Falling Walls: This seems to negate everything I know about mental health. After all, you are supposed to get “professional help”, as they say. But these grandmothers, they are essentially hobby psychiatrists, aren’t they?
Chibanda: Sure, I’ve had a lot of conflicts with professional colleagues over the years. But Friendship Bench is rooted in research, and we have more than 50 peer-reviewed scientific publications describing the different components and why they work. We can stand up in front of any professional group and justify our concept. And honestly, the grandmothers are not out there to take away any jobs from psychiatrists, it is really more about shifting tasks.
Falling Walls: How so?
Chibanda: There is what we call a treatment gap: We simply do not have enough psychiatrists and clinical psychologists, not just in Zimbabwe, but in other countries as well. Even in the UK, people have to wait up to a year before they can see a clinical psychologists. People are committing suicide while they are on a waiting list. It’s ridiculous! So we need to think of models where we use the community and non-professionals to narrow the treatment gap. Friendship Bench is a bridge where the mild and not so severe cases get help before they get to a stage when it becomes severe. Let’s say you have to wait six months for professional help, why not sit down with a grandmother in the meantime?
Falling Walls: You said that you learned a lot about your own profession as a psychiatrist from these grandmothers. What did you learn?
Chibanda: As psychologists, we are usually discouraged to talk about our own limitations with patients. You know the classic setting when the patient is sitting on a couch and the therapist is looking away. Sure, this approach can still work, but I learned from our program that when you share your own vulnerabilities, you reach out to more people. This is something grandmothers are really good at: They bring a human element to therapy, so it feels you are interacting with an actual human being and not just a therapist. We are finding the best counsellors are the one with the most lived experiences.