by Danielle Kuznetsov, AWO Moscow & Health Team Co-Chair
One hundred years have seemed to go by since I wrote this article in September 2019. COVID-19 has completely changed the world, how we live, and how we go about our business.
This article highlights the work of the Friendship Bench in Zimbabwe and the positive effect grassroots mental health endeavors make in a country laden with poverty. I will not rewrite the original, but add an update to connect the dots for us.
Have a quick listen to a description of the program from a BBC interview.
Lockdown happened in Zimbabwe as in all other parts of the world. Although there are fewer reported COVID cases and deaths given a younger population, people stayed home to be safe. I reached out to Dr. Ruth to get an update, but between bad connections and schedules, that follow-up interview has been done in small segments with chicken scratch for notes!
Here is the update:
- Shutdown brought a halt to an economy that already teetered on the edge. People hustled to regroup and retool to be able to feed their families. Dr. Ruth was again amazed at the creativity of the impoverished to not only survive, but work to thrive in adverse circumstances.
- With the hard lockdown in March, the clinics were closed to everything but service emergencies. To keep the “grandmothers” safe, Friendship Bench moved to a phone counseling model. Dr. Ruth made recordings the counselors could listen to for instruction, created WhatsApp groups for communication, new instruction and implementation of data collection, and offered guidance and support as needed.
- Supervision was increased to buffer the issues of confidentiality, cost of phone usage (phone costs are exorbitant), training on how to use phones for those women without smartphones, and the creation of WhatsApp groups to extend the network of mental health support.
- Friendship Bench created electronic business cards that were passed out through the WhatsApp groups to ensure that those people not able to come to the clinic could reach out to someone versed in mental health intervention. Watch a report from Al Jazeera News.
Resiliency. Determination. Hope. – Three words that embody Friendship Bench’s spirit to bridge the gap between giving up and looking forward.
Grandmother Power: Improving Mental Health One Conversation at a Time, September 2019
Before we dig in, I need to set the record straight: I am attempting to write about a complex subject that has long been taboo in general. Only in recent years has the stigma around mental health issues softened, and that is in large part due to the frequency with which the sufferings of the mind have been made public. In this case, exposure is a good thing.
I am attempting to write on this topic because I see a need to voice what seems to be a worldwide epidemic of mental, emotional and spiritual misery. I see a need for prevention rather than remediation. I see a need for understanding to touch all lives so that people do not perish from lack of knowledge.
To be clear, I am not a professional when it comes to mental health. I am not academically educated or trained in the field of mental health or well versed in medical/therapeutic terminology. I am just an ordinary woman curious about herself and others.
I am curious about the meaning of life, happiness and how to have joy when most of what happens is beyond our control. It doesn’t matter where a person is from; everyone has problems that need to be solved. I am curious about relationships and loneliness, hope and desperation, and experiencing life in such a way that loving is made manifest through a surplus of goodness from within.
That is intentional living, and it requires self-awareness and know-how.
The disease of the mind is everywhere. We read about it daily when we read about suicides, celebrity stars in rehab and mass gun shootings. The question that begs to be asked is “How did humanity get to this point?”
As mental health has been a topic in my own family, I frequently read about it to gain a better understanding and skills to deal with it. It wasn’t until researching for this article that I considered the differences in mental health issues between the developing world and the developed world, women and men. I have included resources for your reference at the end of this article.
In the developing world, poverty, war, the lack of appropriate medical care, water, shelter, education and employment, migration, along with gender-based violence are the daily bread of many women and children. In the developed world, the lack of connection and authentic communication, stress from modern life expectations, abuse and isolation keep women and children begging to be seen and heard. Different circumstances, same experience:
– anxiety
– stress
– depression
– post-traumatic stress disorder (PTSD)
– suicide.
It is quite the paradox.
I am sure that there are many programs worldwide that attempt to better the lives of those suffering, and most likely there are programs that differentiate between the genders. However, empirical data for these programs is difficult to find. For this article, I want to focus on one program in Zimbabwe which demonstrates (1) the need to focus on mental health and (2) how to make a difference in a practical, evidence-based way.
This program is led by women lay health workers, and its adult clients are primarily women, but in the youth sector there has been a rise of male clients as well (no publishable statistics yet). Friendship Bench caught my attention last year with a post on Facebook by Dr. Chibanda and his Ted Talk on training grandmothers to treat depression.
When I read that, I wondered, could “regular” grandmas with no clinical education really help others with depression?
A quick look at Friendship Bench’s website highlights what most women and children in developing countries face when it comes to mental health:
Dr. Dixon Chibanda is the founder of Friendship Bench. He was asked by the local government back in 2006 to do something about the problem of depression and anxiety in one of Harare’s townships called Mbare. Dr. Ruth Verhey is the senior psychologist on the Friendship Bench Team and Co-PI on all research projects. She has played a major part in conceptualizing the intervention and the training material of the Friendship Bench Project.
Dr. Ruth spoke with me in August 2019 about Friendship Bench and its work in Zimbabwe:
“The most pressing mental health need is treatment for Common Mental Disorders. CMD is the term for depression, anxiety, PTSD and substance abuse. All of these are very common (hence the name). Substance use is often a result of people having suffered from trauma and having learned to use substance(s) to regulate the emotional pain. What makes FB (Friendship Bench) different is that we can say we are using an evidence-based approach. It is not easy to undertake research (it is costly, it requires academic collaborations, it is lengthy), yet we feel that people have a right to be offered interventions that are clinically tested.”
Indeed, employing an evidence-based intervention in primary care in low-income countries is an impossible feat. Lay Health Worker (LHW) programs began in the 1970s and 1980s as a way to serve needs in areas affected by a health workforce crisis. Although many of these programs were abandoned due to a lack of qualitative data, by using LHWs, FB is achieving just that – a program that bridges the primary healthcare gap and has measurable results. “FB is simple, culturally acceptable, and easily accessible for those who are already underprivileged,” says Dr. Ruth. “The concept convinces those who have experienced it. Problem Solving Therapy also works with the aim of empowering people to help themselves.”
LHWs cadre, known as ‟ambuya utano” (grandmother health providers), are employed by the City of Harare Health Education Unit to work on the ground delivering health promotion to prevent disease outbreaks and promote health. They form a part of a network of 400 health promoters city-wide who are organized geographically and trained and supervised by 15 district health promotion officers.
The average age is 58, and all are female due to the cultural public perception of this work as a caring profession. All LHWs have an average of eight years of health care education (though they are not health care professionals), their previous training is in home-based care for people living with HIV & AIDS, in community follow-up of persons on TB treatment and in delivering community health education and promotion.
Friendship Bench trains the LWHs in Problem Solving Therapy Intervention over a course of eight days. The women are trained to use a structured psycho-assessment called the Shona Symptoms Questionnaire which clarifies the socio-demographic information, the concerns of the individual, mental health symptoms and a risk screening. The LHW is then able to determine the course of action to come next.
Dr. Ruth mentioned, “The elders are definitively respected in Zimbabwean communities. In some cultures, the elders are seen, though, to have all the answers, be right, and have the right to prescribe their answers to others. In Friendship Bench, people get helped to find their own answers after they have defined their problem that they chose to work on.
“PSTI" is a form of Cognitive Behavioral Therapy, which is a treatment that helps people take action in their lives, helping them cope with difficulties, and teaching them to proactively solve their problems. Problem-solving therapy makes use of cognitive and behavioral interventions, helping people directly work on life's challenges.
‟Problem-solving therapy can help with achieving goals, finding purpose, reducing depression, managing anxiety and solving relationship problems. It works by teaching people skills to help them take a more active role in their lives, taking more initiative, and utilizing whatever influence they have to effectively make decisions and achieve their goals. By using this treatment approach with one specific problem, people learn to apply it to other problems they may face, empowering them to face difficulties more independently. As these skills are repeatedly practiced, clients often report an increased sense of confidence and agency in many aspects of their lives.”
Although there is much more work to be done, the LHW role in the treatment gap is very effective. Once a client scores above the cut-off score on the screening tool for CMD, the LHWs meet with them on a bench located in a discrete area of the clinic. This makes it accessible, confidential, and culturally acceptable to have a conversation that opens up the mind. LHWs gain confidence over time and even when dealing with difficult clients or situations. For people who are suicidal, the LHW is able to directly connect that person with a supervisor for more in-depth care. These conversations bring up many run-of-the-mill life issues that feel insurmountable. Financial issues, quite common in low income areas, become the fodder for brainstorming. Given that LHWs are part of the communities and struggle with the same issues, like HIV, clients are able to relax and open up knowing that an understanding person is listening and not judging them. This is when real change is possible.
The local language, called Shona, has the most provocative way to describe CMD that I have ever encountered. To begin with, the word ‟Kufungisisa” means “thinking too much.” ‟Kusuwisisa” means “deep sadness.” ‟Moyo Unorwadza” means “painful heart.” In other words, the ruminating that leads to feeling sad which then drags the body down, making it hard to do much of anything – that’s a pretty good description of depression!
The Western-defined concept of PTSD is described by using a combination of two words in Shona, ‟Kufungisisa Kwe Njodizi,” or thinking too much due to traumatic experience in the past and the interaction with ongoing circumstances in the present, such as poverty, lack of employment, chronic illness, an inability to afford appropriate treatment. This one aspect of the LHWs’ work through Friendship Bench could be an article in itself to open lay understanding of effectively working with PTSD clients.
The intervention is structured over six weeks, with sessions that last 30 to 45 minutes, delivered through the Friendship Bench, and includes home visits when it’s deemed necessary. The first session is generally longer, lasting between 45 and 60 minutes.
The first session includes three components:
- Opening the Mind (kuvhura pfungwa): this includes filling out the questionnaire, careful listening on the part of the LHW, and identifying and defining the problem.
- Uplifting (kusimudzira), which is the exploration of the problem and brainstorming solutions for each issue before deciding which one to focus on. The LHW helps the client to come up with a specific, measurable, achievable and realistic solution. It is important to note that the clients are not told what to do.
- Strengthening (kusimbisa) is the check-in with the client to see how things went. If it went well, then the LHW reassures, praises and offers encouragement. If no progress was made or new obstacles arose, then it requires a revisit to Component 1: redefine the problem and goals and explore what the obstacles were. The LHW and client then problem-solve around the obstacles and decide on a course of action, and the LHW reassures the client.
Finally, they go over where the plan is working, how it needs to be tweaked, where they client might be stuck, and whether there is a need to revisit Component 1.
After four sessions, people are invited to join a support group to continue their work, called Circle Kubatana Tose, or “holding hands together.” Isolation is often part of anxiety and depression, so having this community aspect of the program is essential for further healing.
“CMDs are prevalent globally,” Dr. Ruth told me, “but in the developing world, there are several factors in common that are definitive, such as a high rate of poverty, high level of exposure to violence/abuse (many of our clients report gender-based violence), high levels of unemployment, exposure to sudden deaths of loved ones, lack of access to health care, exposure to the effects of climate change on agricultural production, to name a few. Friendship Bench is a concept that is easily adapted to other settings. We have set it up together with our local collaborators in Malawi and Zanzibar. We focused on language and cultural aspects and found that the concept was accepted easily by our local trainees. We do not really see an issue with using it in a developed-world setting, too. Loneliness is a huge issue in many settings; people need someone to talk to. That is why we also have the peer-led support group as part of the FB. People need to learn to trust each other and talk and solve interpersonal conflict.”
I asked Dr. Ruth if she could address one issue in mental health, what that would be. She answered,
“Teach people safe emotional regulation skills. People who can regulate better will listen more carefully to others, contribute less to interpersonal tensions, which will create a better connection between people and make them feel less rejected and safer with each other. Besides problem-solving, FB teaches the value of being listened to and being accepted without judgement. For many, that is a new experience which allows them to feel safe enough to speak. We believe that people will learn to take these experiences to their communities and in turn also start to pay more attention to how they interact with others.”
In the West, this is called Emotional Intelligence, and it is the new IQ model for success in business. EQ is also grounded in solid data and used widely in the areas of leadership and employee development. Eventually, it trickled into the educational world, adding in Social Intelligence for students – especially those with cognitive disabilities. These are considered the “soft skills” of life; yet without them we are incapable of achieving a high quality of living.
“In Zimbabwe, we have to work on improving health-seeking behavior,” says Dr. Ruth. “There is still a strong stigma attached to mental health problems and people do not seek help. We would like to create awareness around the need for prevention (such as early screens for depression, anxiety, PTSD and substance use disorder). It makes no sense to wait for a condition to fully develop before help is offered.”
Indeed, prevention is the key to making a difference. The World Health Organization states, “Around 450 million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide.” The United Nations health agency seeks to break this vicious cycle and urges governments to seek solutions for mental health that are already available and affordable. “Governments should move away from large mental institutions and towards community health care, and integrate mental health care into primary health and the general health care system.”
People learn by experience. The Friendship Bench gives women just that – a practical and effective experience of being heard and of learning a new way to think, feel and do! An experience of self and clarity of mind. An experience not based on ever-changing externals, but of finding the courage and inner strength to see the way through it.
So much of our lives as women is the process of unlearning and letting go of what no longer serves us, especially in an ever-changing world. Having the skills to navigate those changes and create better lives for ourselves is something that gets passed down, generation to generation, and must be invested in.
I believe it is the same for all women everywhere. We are the daughters, wives, mothers, sisters, friends, caretakers and teachers, as well as the myriad of capacities we hold in the marketplace. We have been endowed with great power to create, empower and lead. It is our mouths and hands that shape and guide, teach and instruct, mend and heal. We are the curators of humanity and culture.
Even in the face of adversity, discrimination, and prejudice, it is the inalienable right of women everywhere to rise up, take charge, and enact change to serve and better those who come after us. It is our collective identity – yours and mine. For those of us privileged enough to live in the first world, we must not only acquire the skills to do that in our own communities, but also to equip our sisters burdened by poverty and abuse; whether that be across the ocean or in our backyard. From those to whom much has been given, much is required.
Friendship Bench offers us a great model for hope and a DOABLE simple approach for ordinary LAY women like us. Thank goodness for organizations like FAWCO that afford us the opportunity to combine our time, talents and resources to act in charity and love. And of course, be challenged to learn new skills to impact the lives of others.
Resources:
https://friendshipbenchzimbabwe.org/mediacentre
Chibanda D, Weiss HA, Verhey R, Simms V, Munjoma R, Rusakaniko S, Chingono A, Munetsi E, Bere T, Manda E, Abas M. Effect of a primary care–based psychological intervention on symptoms of common mental disorders in Zimbabwe: a randomized clinical trial. Jama. 2016 Dec 27;316(24):2618-26.
https://www.friendshipbenchzimbabwe.org/team
Abas, M., Bowers, T., Manda, E., Cooper, S., Machando, D., Verhey, R., Lamech, N., Araya, R. and Chibanda, D. (2016). ‘Opening up the mind’: problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the Friendship Bench Project in Zimbabwe. International Journal of Mental Health Systems.
https://www.friendshipbenchzimbabwe.org/about-us
Verhey, R., Chibanda, D., Vera, A., Manda, E., Brakarsh, J. and Seedat, S. (2019). Perceptions of HIV-related trauma in people living with HIV in Zimbabwe’s Friendship Bench Program: A qualitative analysis of counselors’ and clients’ experiences. Transcultural Psychiatry, p.136346151985033.
Cognitive Behavioral Therapy Los Angeles. (2019). Problem-Solving Therapy — Cognitive Behavioral Therapy Los Angeles. http://cogbtherapy.com/problem-solving-therapy-los-angeles
Who.int. WHO | Mental disorders affect one in four people. https://www.who.int/whr/2001/media_centre/press_release/en/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3039289/
https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers