It all started with the suicide of a patient whose family could not afford bus fare to the hospital.
The tragedy was a turning point in the life and career of psychiatrist Dixon Chibanda, founder of the Friendship Bench program. His focus was developing a community-based approach to therapy that leverages the power, compassion, and accessibility—of grandmothers. Today, the mental health initiative that began in 2007 in the township of Mbare, Zimbabwe, has expanded within the country and has been replicated around the world.
As part of the McKinsey Health Institute’s (MHI’s) Conversations on Health series, Chibanda sat down with Kana Enomoto, director of brain health at MHI, to discuss the Friendship Bench; the role of communities, policy makers, and other stakeholders in building capacity for mental health programs; and the post-COVID-19 opportunity for driving innovation. The following is an edited version of their conversation.
Kana Enomoto: What started you on your journey focusing on mental health? And what inspires you to stay on this path?
Dixon Chibanda: From a very early age, observing tension in my own family—the relationship between my father and mother—affected my mental health.
At the time, I didn’t know this was something that could be defined as mental health. When I got to medical school, the death of a colleague who took his own life was the turning point that really opened my eyes. I started asking a lot more questions about mental health and what it was.
Kana Enomoto: Where did you get the idea for the Friendship Bench? It seems like such a wonderful solution to the challenge of people not living close to hospitals, not wanting to go to a clinic for care, or not having enough clinically trained professionals to reach everyone in need.
Dixon Chibanda: The idea of the Friendship Bench was born out of a personal tragedy as a psychiatrist. Erica was a patient I was seeing for just over three years when she took her own life. I think the real tragedy about Erica’s loss was that she knew she needed help; her parents knew she needed help; but they did not have the $15 bus fare to come [from their remote village] to the hospital where I worked, some 200 miles away, for a follow-up.1 And I was hit hard by the realization that I had taken for granted that people who needed my services could find me at the hospital. That was really the beginning of a soul-searching journey to find my place in the world, as a psychiatrist but also as a human being. I realized I had to take psychiatry out of the hospital, into the community.
Kana Enomoto: Can you tell me more about the Friendship Bench model, how it works, and how it’s been received?
Dixon Chibanda: The Friendship Bench—in really simple terms—is a brief psychological therapy, or talk therapy, that is delivered predominantly by community grandmothers who are trained in the very basics of cognitive behavioral therapy. After that training, which normally takes a month, they are allocated a wooden park bench in their communities. Our team then facilitates referrals to those benches through social media, primary healthcare facilities, schools, and police stations. The grandmothers then screen everyone who is referred to them using a locally validated screening tool. Selected cases go on to receive this structured therapy on the bench, and, after two to four sessions, they are invited to join a support group within the community where they begin to collectively problem solve around common challenges. Friendship Bench starts off as a one-on-one therapy between a grandmother and a client, then goes on to a peer support system that can go on and on. We have groups that have been running for more than eight years.
Kana Enomoto: What kind of outcomes are you seeing?
Dixon Chibanda: One of the strengths of Friendship Bench is that we are really embedded in research. We have close to 100 scientific, peer-reviewed publications on the Friendship Bench. Our very first publication, which I consider to be our seminal paper, was a cluster-randomized controlled trial published in the Journal of the American Medical Association.2 That initial paper showed a significant improvement in depressed participants who received therapy from a trained grandmother. At six months, those receiving therapy from a grandmother were much better off than those who received therapy from a trained community mental health nurse or psychologist.3 And that, for us as a team, was the first major groundbreaking evidence that propelled Friendship Bench to the next stage, where we realized this model could probably be taken to scale, and we needed to train more grandmothers.
[The outcomes] propelled Friendship Bench to the next stage, where we realized this model could probably be taken to scale, and we needed to train more grandmothers.Dixon Chibanda
One of the reasons grandmothers are so great for this is because they are rooted in their communities; they are considered custodians of local culture and wisdom, and they don’t leave their communities; they are so reliable. This year alone, we’ve trained 1,200 new grandmothers who are providing Friendship Bench therapy in Zimbabwe. Additionally, we have a presence in a number of countries where we have replicated the model, most recently in Vietnam. It’s exciting to see the traction we’ve gained over the past couple of years.
Kana Enomoto: How many Friendship Bench programs are there? What’s your reach so far?
Dixon Chibanda: This year in Zimbabwe, since January, we have managed to reach out to just over 60,000 people. Unfortunately, the numbers outside of Zimbabwe are not very reliable, but I do know for sure that the first year we piloted the Friendship Bench in New York City, in the Bronx and Harlem, 60,000 people sat down to receive therapy from one of the “Friendship Benchers,” as they call themselves. We’ve seen similar results in places like Kenya, where we have Friendship Benches in tea estates, in Kericho. One of our most successful Friendship Bench programs outside Zimbabwe has been in Zanzibar, where the Ministry of Health is scaling it across the island. Looking at the numbers inside and outside Zimbabwe, we have reached close to half a million people in the past three years. And that’s actually not enough when you think of the magnitude of the problem and the care gap that exists for common mental disorders. Our vision is to see a Friendship Bench within walking distance—everywhere.
Kana Enomoto: At MHI, we have a pillar on healthy aging—adding not only years to life, but life to years. And part of that is having a purpose. Are you looking at the impact of being a Friendship Bencher for the grandmothers?
Dixon Chibanda: Yes. A colleague of mine, Dr. Ruth Verhey, who’s been doing a lot of international training has, for her PhD, looked at the effect of Friendship Bench on the grandmothers as delivery agents. Her findings show that the grandmothers working on Friendship Bench were a lot more resilient and less likely to have PTSD [post-traumatic stress disorder] and other common mental disorders. When you go deeper in the research, the common thread or response from the grandmothers is that it gives them a sense of purpose.
One of the reasons we see poor mental health across the life span is when people lose that sense of purpose, we become more vulnerable—not only to mental-health-related challenges, but to physical health challenges as well. This is a win–win for the grandmothers and the clients who come to sit on the bench.
Kana Enomoto: Can you speak to why you think it works across differently resourced environments?
Dixon Chibanda: I think one of the challenges that we are seeing in the modern world today—particularly against the increasing technological development—is the disconnect, this inability of human beings to be together. This is why Friendship Bench works, because Friendship Bench is not primarily marketed as a clinical intervention.
It’s really marketed as an intervention to create space for people to get together to talk.
We are seeing a lot of what we are calling intergenerational connectedness, where that wisdom and cultural knowledge from the grandmothers helps the young people who are struggling to find meaning to be a lot more rooted in their communities and find a sense of purpose and direction in their lives. At a basic level, this is why Friendship Bench resonates with a lot of people across the world. The big picture is not just about mental health; it’s about humans connecting with one another.
Photo courtesy of Friendship Bench
Kana Enomoto: Absolutely. [US surgeon general] Vivek Murthy, in his book Together [Harper Wave, April 2020], says we have a universal need to connect with one another, and most of us are connecting with lonely people all the time even if we don’t realize it. Our MHI modern understanding of health combines physical health and mental health with social health and spiritual health. Friendship Bench seems to combine many of those things. Have you looked at the impact on physical health?
Dixon Chibanda: We have recently looked at the impact of Friendship Bench on diabetes and hypertension. Our findings—not yet published—show that by integrating Friendship Bench into these traditional noncommunicable disease conditions, you improve the outcomes. What we’re striving for at Friendship Bench is to have a very holistic approach, not one focusing just on mental health issues.
The first thing a grandmother will say when you sit on a bench is, “Would you like to share your story with me?” And that’s where the power comes from—when people begin to narrate their own personal stories, sufferings, and journey. Through that journey, you can pick up on the nuances, the lifestyles, the risk factors, the social determinants of not just mental health but health in general.
Kana Enomoto: How did COVID-19 affect Friendship Bench? And what do you see as the post-COVID-19 opportunity for mental health?
Dixon Chibanda: Naturally, during COVID-19 we were very concerned about the grandmothers; they are vulnerable. And we pivoted around that crisis by introducing a digital Friendship Bench. COVID-19 gave us an opportunity to test Friendship Bench on a different platform. The other thing that emerged as a result of the pandemic was just a greater awareness of mental health issues at the community level and—in my country, Zimbabwe—by the policy makers. Friendship Bench has now been integrated into the national strategic plan for health. That is recognition of the work that we are doing. The third thing that’s happened as a result of the pandemic is the acknowledgment, by a lot of traditional funders who were not in the mental health space, of the need for funding mental health.
Kana Enomoto: What have you found was most effective in persuading people that this is in fact a valuable investment for their communities and their people?
Dixon Chibanda: Over the years, what I’ve found really effective is working with people at the grassroots level—the proximal leaders, community gatekeepers, community stakeholders—and involving them in the whole process of developing an idea. That gives a lot more weight to the policy makers. My suggestion would be to always think of cocreation and coproduction before you take an idea to the policy makers. Another one of the lessons I’ve picked up is that the community itself is a lot more powerful than the policy makers. In a lot of ways, Friendship Bench has, for a very long time, been running on its own without getting the policy makers involved.
Kana Enomoto: You mentioned you don’t often focus on specific diagnoses. Has there been resistance, or have you seen progress in people’s willingness to talk about these things?
Dixon Chibanda: As psychiatrists or professionals in the field, we need the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition] or the ICD-10 [International Classification of Diseases, Tenth Revision] to put structure in the work that we do. But at the same time, when we medicalize and put people in these categories, we are also removing people at the community level who might otherwise want to help. Because the minute we medicalize things, the instinctive knee-jerk reaction I’ve seen in communities is, “This is for the professionals. We can’t deal with it. You have to be referred to a clinical psychologist.” And yet, the first port of call to address a lot of these challenges should be the community. The challenge is: How do you empower communities to have the confidence to be able to address these issues? The answer, at least from the work I’m doing with Friendship Bench, seems to be removing that medicalization.
For example, when I first started Friendship Bench, I called it the Mental Health Bench. And nobody wanted to come to the Mental Health Bench. The grandmothers approached me and said, “That is stigmatizing. You need to change the name.” We changed it to Friendship Bench—and people started coming to the Friendship Bench. The services we were providing were exactly the same. So the names that we attach to certain conditions, certain interventions, are critical. It can make or break the work that we do in the global mental health space.
At Friendship Bench, we’ve moved away from using clinical terms. We talk about kuvhura pfungwa, which is a Shona word for “opening up the mind”; we then talk about kusimudzira, a Shona word for “uplifting.” Then we talk about kusimbisa, which is “strengthening.” We use this kind of language because communities resonate with it. And when you use language they resonate with, you remove stigma. On the other hand, if you use terms like depression, schizophrenia, bipolar disorder, you create division. There is certainly room for those terms when we are communicating as clinicians. But within communities, I’ve found that you get better results when you remove all those labels and simply look at the human being and listen to their story.
Kana Enomoto: You talk about opening up the mind, uplifting, strengthening. I feel like this conversation with you today has done that for me. Any words of wisdom you’d like to share in closing?
Dixon Chibanda: We can all reach out to those who are in need. The first building block is expressed empathy, the ability to make people feel respected and understood, and bring all of that in the present moment. Anchor your expressed empathy in the now. Because it’s only “the now” that we really have. We spend a lot of time in the future and in the past. But if you bring expressed empathy into the now, and you anchor that into the present moment, healing begins.