Depression? Why not sit down with a grandmother?

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.

Falling Walls: Can you give me an example?

Chibanda: In New York City, where we have Friendship Benches in the Bronx and in Harlem, there is this one woman named Skip. She spend a long time in prison, she did drugs, all sort of things. Now she sits on a bench and talks to someone with a drug problem or who has just been released from prison and she has this powerful connection due to her own lived experiences.

Falling Walls: Are there any grandfathers involved?

Chibanda: When we started, we also tried grandfathers and of course it can work, but the problem is that they are often not capable of giving people the space to tell their stories. They are not patient and empathic enough and they have a different body language. Men tend to be very instructive, they listen briefly and then they tell you what to do, which is not what Friendship Bench is all about. We want patients to come up with their own solutions, to give them a sense of ownership.

Falling Walls: You also mention the use of digital platforms. Can you elaborate on that?

Chibanda: We have developed an App called Inuka. It give people a platform to receive support after they leave the Friendship Bench. If you feel the need to talk but you are too far away, you can use the app. It is also helpful for young people who feel uncomfortable coming to the bench. It is like an electronic version of the Friendship Bench and it is picking up in the countries where we have launched it.

Falling Walls: Speaking of launch, the Friendship Bench program can be found in many African countries by now and even in the US. Could this also work in Europe or Germany?

Chibanda: Last year, in New York City alone, 60.000 people sat on the Friendship Bench. We are trying it out in London as well and the results are quite positive. I think a lot depends on how it is introduced and on who provides the service. Another thing important thing is that it’s not just a place for treatment. We prefer to look at it as a place that helps to create space for healing, because that’s what most people need. A space to address loneliness. Even in the developed world, loneliness has become an epidemic. Not everyone who comes to the bench meets the diagnostic criteria of depression, they are simply lonely. Humans all over the world yearn for acceptance and human contact and that is provided on the bench, no matter where they are.

Falling Walls: Can you ever look at grandmothers and not think of them as counsellors?

Chibanda: Actually, I can’t. I keep thinking of we and the whole world is not tapping into this important resource, which is characterized by years and years of personal and lived experience. Being able to tap into to that, not only to address mental health issues but to make the world a better place.

Interview by: Eike Kühl