The Friendship Bench

When people experience profoundly damaging events, like war, invasion, or massacre, the psychological toll is vast. Which interventions work best to help repair the damage? Dixon Chibanda pioneered the Friendship Bench, where local grandmothers sit with people and help them talk through their problems. In this talk from EA Global 2018: London, Chibanda explains his program, which has shown impressive results in reducing depression among participants.

A transcript of Dixon's talk is below, which we have lightly edited for clarity. You can share your thoughts about the talk on the EA Forum.

The Talk

I come from Zimbabwe, a country which is often characterized by several decades of psychological trauma, from the Rhodesian Bush War, the farm invasions, the massacre of more than 20,000 people in Matabeleland, and so the Friendship Bench is in essence a program that was conceived as a result of one such traumatic piece of history from our country, which actually started on the 19th of May in 2005, when the Zimbabwean government at the time, under the leadership of Robert Mugabe, embarked on a cleanup operation which was called Operation Murambatsvina, which literally means "Removing the filth."

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And what Operation Murambatsvina was all about was a systematic destruction of buildings, structures that were labeled by the government as illegal, whatever that meant at the time, and it resulted in over 700,000 people being left homeless, and according to the United Nations, over two million people were psychologically affected as a result of this operation. During that time, I was studying for my Master's in Public Health, and I was instructed to carry out a survey to establish what the prevalence, or the magnitude of the psychological morbidity was, and when these results were presented to the authorities, I was then told, "You need to really come up with some kind of intervention."

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A whole lot of things were happening at the time, and of course in a country where there were absolutely no resources, and most of the professionals had left. I was in essence given a group of grandmothers to work with, 14, to start a program, or pilot, something that would eventually help thousands of people, and it was pretty depressing initially. And anyway, to cut a long story short, through an iterative process with these 14 grandmothers, we gathered as much information as we could about programs that had been developed in the country, outside the country, and we essentially through this iterative process tested different approaches, which were rooted in cognitive behavioral therapy.

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And over a couple of months, we managed to come up with a meaningful sort of intervention, and over the years we developed a series of components to this intervention, which became known as the Friendship Bench, which in essence is psychological therapy which is delivered on a bench in the community by grandmothers. And one of our most recent publications is a clinical trial of this intervention, where we compared the Friendship Bench with usual care, through a cluster randomized controlled trial. And the cluster randomized controlled trial, which is published in the Journal of the American Medical Association actually showed that grandmothers were more effective at delivering and alleviating symptoms of depression and averting suicides than usual care.

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And usual care included nurses trained in mental health, psychologists, and also the use of Prozac, so grandmothers were pretty effective at doing their job. And to actually illustrate what we've achieved over the past couple of years and where we're going, we divided the Friendship Bench into three main components. The first part was the research and development, which was really the formative phase of Friendship Bench, where in the absence of resources we had to come up with an intervention which was simple, cheap, but was addressing a huge problem, and apart from that we needed an intervention that would address a diverse population.

And we managed to kind of achieve that, looking at Zimbabwe as an isolated country, but really when you're thinking of an intervention that is likely to be scaled up it has to be replicated, and so we were thinking of the next stage, which is replication. Can the Friendship Bench in its current state be replicated in places outside of Zimbabwe? And if it can be replicated then it can really go to scale? So we started the process of replication in Malawi, in New York City, in Zanzibar and Botswana, and the model seemed to be quite intact in terms of its replicability in different settings, different cultural settings, and so we're kind of confident that this really can go to scale.

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Now, one of the things that we observed while we were running the Friendship Bench is that not all young people were comfortable sitting on a bench with grandmothers, and also we realized that some people preferred to communicate a lot more using digital technology, mobile phones with the grandmothers. So we teamed up a couple of years back with folks from Philips, with Robin and others, and we came up with an intervention which supports Friendship Bench called Inuka. Inuka is a Swahili word which means "Arise," and the rationale behind it is, if Friendship Bench can be scaled up, Inuka as a digital platform could enhance that scaling-up process, and so in essence Inuka becomes a digital platform. This is in addition to the existing Friendship Bench, which has been running since 2006. It's an app which can be downloaded, and it's really based on the same principles of the Friendship Bench.

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And the idea is with this approach of having these grandmothers, for instance, in Zimbabwe who deliver an intervention on a park bench in the community, and at the moment we are operating in more than 70 communities in the country, and obviously we also have communities outside of Zimbabwe. With that kind of intervention, which is then supported using digital platforms, we are able to reach out to more people. We are able to provide a lot more support to the grandmothers via these digital platforms, and this has been reflected in the work that we've been doing in New York City, for instance, in Zanzibar, where there's a need for that digital platform. At the moment, some of that digital communication is facilitated through WhatsApp, you know, through Skype, and so Inuka comes in as something that could effectively take over that role and enable strengthened communication to really enhance our reach and impact.

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I'd like to share some of the Sustainable Development Goals which specifically focus on mental health, just to highlight why an intervention like Friendship Bench is important. So if you look at target 3.4, 3.5, and 3.8, they all touch on mental health, and there's this growing need when you look at the global burden of mental, neurological and substance use disorders, there's a real need to scale up interventions that truly reduce that treatment gap for mental, neurological and substance use disorders. We cannot train enough psychiatrists or clinical psychologists, that is common knowledge. However, through task-shifting we can make a huge difference in a very short space of time, but the challenge is finding task-shifting interventions which are really solidly rooted in evidence, which are based in empirical observation.

I believe that the Friendship Bench is one such intervention which can contribute significantly to reducing that treatment gap. I'll get on to why I think grandmothers are also a critical role, or the elderly population in the world, a little bit later. Just to give you a few examples from two very different locations: Zimbabwe and New York City.

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Here we have the oldest graduate from Zimbabwe, she's 84 years old, and the lady on the right is from New York City, her name is Skip, and the common thing that really unites or brings these people together are the lived experiences which they bring on the bench. This is something that we've found to be really powerful, where or the stories that people bring to the bench are rooted in CBT principles, and empirical observation, because the whole thing is about measurement.

If we can't measure what we're doing then we really don't know if it's working, and so by bringing in and injecting something like CBT and the use of validated screening tools, while you give stories, you're able to tell how a person is improving, what kind of progress that person is making. And so what has essentially happened over the years is something that started off as a strongly CBT-based intervention has really become more of CBT through storytelling, CBT through the use of evidence-based tools which are validated within a local context.

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This is a picture that I often like to use to illustrate the power of using ordinary people in communities. This is a picture of the very first grandmother who worked on the Friendship Bench in Zimbabwe. Her name is Grandmother Jack, and Grandmother Jack was the first person who started doing this work, and she gave hope to all of us because she was really dedicated in what she did, and she would persistently be there every morning seeing her clients. It was something that we expected of her to do, you know, and one morning when she didn't come to work, we kind of all knew what had happened to Grandmother Jack.

But what really illustrates the Grandmother Jack story is that if you think of the world's elderly, the population of elderly people in the world today, you know, if you look at 65 and above, it's estimated by the World Health Organization and the UN that there are over 600 million people aged 65 and above, and then within another 15 years it's going to be over a billion people aged over 65, and the older one gets, the richer the lived experience is.

And what we are learning from the Friendship Bench is that if we can take those lived experiences and inject a fair dose of evidence-based talk therapy, they really can reach out to thousands of people addressing the global burden of depression, for instance, and contribute significantly to averting suicides. This is what we have seen in Zimbabwe, we've seen this in Malawi, we are seeing this in New York City, we are seeing it in Zanzibar, and more recently in Botswana. So this is what I really wanted to share with you about the work that we're doing in Zimbabwe, and why I think that this kind of work can make a difference, and this kind of work is really what's going to contribute significantly towards narrowing or reducing the treatment gap for mental, neurological, and substance use disorder on a global scale.

If anyone is interested in learning a little bit more about the Friendship Bench, you can look up my TED Talk, which goes into more detail of how the Friendship Bench actually works.


Question: On the bench, what does a person experience? What is the nature of the experience as people actually have it?

Dixon: Sure. So, the Friendship Bench model consists of two critical components. The first component is the preparation of the grandmothers, so in essence what we do is we first train trainers. The trainers then train the grandmothers, and the trainers that train the grandmothers end up supervising the grandmothers once the grandmothers are in the field. And the actual CBT component consists of three steps, very simple steps, which are rooted in behavior activation, activity scheduling, and in problem-solving therapy.

The first component is called "Opening the mind," in Shona it's called "Kuvhura pfungwa." The second component is uplifting, and the third component is kusimbisa, and how it essentially works is people are referred to the bench from everywhere, from schools, from the police station, from the clinics, from homes, and some people just self-refer. Some are referred through radio talk stations, and when they come to the bench the first thing that happens is they are screened. They are screened using a locally-validated screening tool. I think here in the UK with IAPT you use PHQ-9. We also use the PHQ-9, but we also have a very specific locally-validated tool called the SSQ, which is broader.

And screening tools are critical, because if you don't use screening tools in this kind of work, it's difficult to have structure. So the screening tools inform the grandmothers whether they are dealing with a severe case, a moderate case, a case that needs to be referred to the next level, and so once they establish that this is a case, they then provide the talk therapy, which is really consisting of those three steps, and normally it's over a series of about four sessions.

Question: Can you describe each of those three steps in a little bit more detail?

Dixon: Opening the mind essentially is the storytelling part, where the grandmother listens to the stories. So you know, classically people who come to the bench have a whole lot of problems. A whole lot of issues, everything is just kind of going wrong in their lives, and people will often present with a number of problems, not just one problem. A person may present with being HIV positive, unemployed, having no place to stay, having children who are not at school, you know, just a whole lot of problems, and what we've also realized is when people present with these kind of problems, they get into a kind of learned helplessness, where they can't really figure out which problem to start working on.

An interesting thing is, we thought this phenomenon was specific to Zimbabwe, but we see exactly the same thing in New York City when we look at the cases that they are dealing with in the Bronx and in Harlem. It's pretty much the same, people with all these problems and just not knowing where to start, and sitting on the bench and having somebody say to you, "Tell me your story," is just such an amazing way of opening up, and realizing that there's actually someone who can listen to you, someone who can help you. So that's really the first stage, opening up the mind through opening up and telling those stories, as painful as they are.

And one of the other things which we also encourage on the Friendship Bench, which is really not in-keeping with your usual psychotherapy or CBT therapy is that the therapist becomes almost involved. And this is something that I was never trained to do as a psychiatrist, you know? You always keep your distance, but we've learned from the grandmothers that it's critically important to show your weaknesses too as a human being, by sharing your own lived experience, but within a very structured way, and by doing that you really establish strong rapport with the client.

So anyway, so the client talks about their story, and while they're doing that the grandmother simply lists the problems that are highlighted. That's all she does, and she listens with a lot of empathy, with a lot of appropriate physical gesture where called for, and after all of that has happened the grandmother simply summarizes what she hears. And that particular component is also very powerful, because when somebody tells you their story and you are able to accurately summarize what they've told you, that's a sign that you've been listening, and that's a sign for that person who's telling their story that, "I've got someone who's on my side."

And really, that's why we call it "opening up the mind," because most of these people have never really talked about their problems to anyone in such a setting, and so when that happens the grandmother then summarizes, and after summarizing asks the client to select a problem to work on, so like your traditional PST, you know, and then it goes on from there, where they brainstorm to come up with a solution, and essentially come up with a very specific, measurable, achievable, realistic and timely solution that they focus on. Very, very practical, but with a very strong dose of emotions and human contact.

Question: It strikes me that this is also sort of an instruction manual for how to be a good friend.

Dixon: Well, that's why it's called "Friendship Bench!"

Question: So, you've kind of recounted now to your client, "Here's what I heard from you," and then uplifting is this kind of brainstorming?

Dixon: Yeah.

Question: Choosing a particular thing to sort of focus on first, brainstorming solutions to that. What is the strengthening phase?

Dixon: So, the strengthening phase is essentially the part where you then start to clearly identify a single problem and break it down in terms of what happens, but a critical component of the strengthening phase is something that we call "The holy cow moment." And we call it "the holy cow moment" because it's one of those stages in therapy where the therapist is interacting with the client and you've listed all these problems, and I used to struggle with that, you know? So you list all these problems, you know, "I'm suffering from HIV, my neighbor is not talking to me, my husband is abusive, I have a pregnant teenage daughter," and with my mind as a medical doctor and psychiatrist, when I hear HIV, the first thing I think of, "We've got to put this person on medication. We have to make sure that the CD4 count and the viral load is all in place."

And then when you actually discuss with the client, and the client identifies a problem to focus on which just doesn't fit with you and your thinking as a psychiatrist, that's what we call the "The holy moment," and we struggled a lot with the holy moments with the grandmothers as well, because initially they would prioritize certain things, but we also realized that handling that "holy cow moment," where a client selects something that seems really ridiculous to focus on, is critical. And what we essentially do is we encourage the grandmothers to deal with the "holy cow moment" as it comes, so if a client chooses to focus for instance on something which seems trivial, focus on it, because what we've learned over the years is by focusing on that which seems trivial to us, we actually are opening up avenues to treat all the other problems that seem massive.

So that becomes the strengthening component, where the client realizes that, "Regardless of the problem that I've selected to focus on, this person is still prepared to work with me." And once that is done, the third stage which is the strengthening, kusimbisa, is in essence the homework. Because the beauty of what we do on the Friendship Bench, which is different from your traditional therapy, is your first session, the focus is to make sure that you walk away from there with a solution. We don't believe in telling people to come back for three, four sessions before a problem is solved. You know, people in Africa are very mobile, they're constantly moving, and if a person spends an hour and a half with you and you can't solve your problem, they're pretty much not going to come back.

So we really do emphasize on making sure that they go home with something tangible that they can work on, that's the strengthening, and then part of the strengthening involves the grandmother calling up on the client, either by sending an SMS, or sending a WhatsApp message, and just to touch base, to see how the client is doing, and this strengthening carries on because they will meet sometimes outside, when they are in the marketplace or in the community, and she can do a five minute strengthening. "So how is it going? How are things?" You know, that kind of stuff, and so that carries on.

Question: Is it validated that grandmothers in particular are the right people to be doing this, versus any other group of people?

Dixon: So, for Zimbabwe certainly grandmothers are the best. We have consistently found that grandmothers are reliable. You know, they are rooted in their communities and they have this wealth of wisdom which is very culturally appropriate. They are very good with using appropriate proverbs to actually get through a problem, and they're just... they give very good hugs as well, you know? So for Zimbabwe certainly, we certainly love the idea of grandmothers, but we are also working with young people. If you go to New York City, they don't have that many grandmothers. New York City I guess has a very diverse group of people working on the bench, from about 24 years old all the way up to like 56, so that's what works for New York City.

I'm strongly in favor of working with grandmothers for the simple fact that we find them to be more reliable, but I think this model can be used for anyone. Anyone can deliver this model, and the grandmothers that we're working with, as I indicated in my presentation earlier on, in essence I was given grandmothers. I guess the city health department thought that grandmothers are not so important, so try and come up with a solution with grandmothers, and the nurses and other mental health professionals were busy doing other things. So it's not that I chose them. They are what I had to work with, which was a blessing in disguise, actually.

Question: Who funds your organization? Are you looking to expand, are you looking to start something in the UK? What could you do with more funding? All of that has been asked.

Dixon: So, I mean obviously we would love a lot of funding. We run a trust called the Friendship Bench Trust. So initially when we started Friendship Bench, as I indicated in my presentation, was really my thesis, my fieldwork for my Master's in Public Health. That's really how it started, and it just carried on since 2006. It has grown, and we are now a Trust, a registered Trust in Zimbabwe. We are hoping at some stage to be registered here in the UK, because I'm kind of affiliated to the London School of Hygiene and Tropical Medicine, so that's the idea.

Most of our work has been funded by research agencies like the Wellcome Trust, NIH, MRC. This is why our work is heavily research-based, but we also do realize that as we think of scaling up the Friendship Bench, we really need to move to a different kind of funder, because most of these research organizations or funders do not fund scaling up of programs, and I think the Friendship Bench has acquired quite a lot of evidence to justify taking that next step, which is scaling up. Yeah.

Question: For those that are interested in kind of going a little bit deeper into the subject matter, are there any self-training materials that people could access somewhere online?

Dixon: If you go to the Friendship Bench website, we do have a manual that is available that we use. We have a facilitators' manual, and we have a training manual for the delivering agents, but we also have the Inuka platform, which offers the training of guides as I indicated earlier on. You've got Friendship Bench, which was the original program which started in Zimbabwe, and now we have a digital component which is really based on what we've done in Zimbabwe, and for Inuka we actually hopefully wanted the gains to run smoothly. At the moment we are testing Inuka. Inuka has been tested, piloted in Zimbabwe, in Kenya, and we've done some work in India, so at the moment we are actually running a pilot in Kenya, but we would love to have guides on Inuka once it starts to run.