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How community-based talk-therapy is tackling Africa’s mental health crisis



By Patrick Egwu

Africa has a mental health crisis. More than 116 million people are estimated to be living with mental health conditions, according to the World Health Organization (WHO).

However, in Zimbabwe, Friendship Bench, a community-based talk-therapy is providing solutions to people struggling with common mental health disorders. 

Friendship Bench is designed as a community project which selects and trains grandmothers and other volunteers in cognitive behaviour therapy using evidence-based talk therapy in local communities, according to Dixon Chibanda, the founder of Friendship Bench.

Chibanda said the grandmothers are custodians of local wisdom and culture in Zimbabwe.

“They sit on a bench while offering counselling and mental illness services to support community members through issues like depression and anxiety,” he said, explaining how the therapy session works. 

In the absence of trained mental health care practitioners, the WHO recommends the assignment of lay counselors to provide mental health care services under the supervision of professional psychiatrists.

Friendship Bench uses the grandmothers in the form of lay counselors. They are primarily community volunteers without expert training in health care.

Experts train the grandmothers at Friendship Bench on providing counselling and mental health services using 6 sessions of problem-solving therapy. 

The project is a proven evidence-based intervention found to reduce common mental disorders among adults attending primary health care clinics. 

Friendship Bench has been running since 2005 and has helped more than 40,000 people receive care in 2018 alone. 

There is a general acceptance of the mental health program across Zimbabwean communities, Chibanda said. In the last ten years, Zimbabwe has seen a growing interest in the use of lay health workers to reduce the treatment gaps for common mental disorders.

A grandmother conducting a problem-solving therapy session with a young female client on the Friendship Bench at a primary care clinic in Harare, Zimbabwe. Photo credit: Friendship Bench

For instance, over a ten-year period, more than 150,000 people have received mental health therapies from the grandmothers. In addition, 1,617 community workers have been trained to offer therapies to mental health patients. 

Poverty and social economic issues are some of the factors exacerbating mental health issues across Africa.

According to the WHO, more than three-quarters of the people with mental challenges in low-and-middle-income countries receive no treatment due to lack of trained mental health experts. 

A 2022 study by Chibanda and his colleagues published in the Journal of Mental Health, says “the absence of social safety nets, and the presence of poverty, food insecurity, impairment of social and occupational functioning (eg, loss of income and recreation opportunities), and uncertainty have predisposed the Zimbabwean population to poor mental health as in other low-resourced settings.”

The study says if untreated, mental health problems may lead to poor daily functioning, economic losses due to lost productivity at work, risky sexual behaviors, substance misuse, relationship instability, suicidal ideation, and increased health care resource use, which can further pressure fragile health care systems.

A similar study of adults with suicidal thoughts in Zimbabwe, found that problem-solving therapy delivered by trained and supervised lay health workers reduced common mental disorder symptoms among participants.

Dixon Chibanda (Friendship Bench Founder) sitting with a group of Grandmothers discussing how their work is going and what they are seeing in the community. Photo credit: Friendship Bench.

The study sampled 573 participants who were screened positive for common mental disorder symptoms, and 75 (13.1 per cent) reported suicidal thoughts. The suicidal thoughts were associated with being aged over 24, lack of household income and having recently skipped a meal due to lack of food. 

Chibanda, who  is also an Associate Professor of Global Mental Health at London School of Hygiene & Tropical Medicine, says Friendship Bench help in the reduction of depression and suicide ideation by 86 per cent.

He added that the real solution to mental health issues has to be delivered from the bottom up by “integrating our culture in the way we address challenges that society is facing.”

Mental health support during the pandemic

Lockdowns and other COVID-19 pandemic restrictions exacerbated mental health issues around the world. The WHO said that mental health issues increased by 25 percent in the first year of the pandemic. 

In Africa, access to in-person mental care was disrupted as victims were in dire need of interventions. 

Kelly Muzariri, the project coordinator at Friendship Bench said the pandemic worsened mental health issues and put victims at risk of escalation. 

Due to government-imposed restrictions, Friendship Bench switched online to offer customized services for mental health victims at no cost.

Using a mobile chatting platform, WhatsApp, the project introduced trained specialists called “open-liners” who provide counseling sessions for victims. 

The “open-liners” provide a secured line where clients who need counselling services call in to book sessions and speak with an attendant. 

Every week, the services run from Monday to Friday from 8 a.m to 5 p.m with a session lasting 30 minutes up to one hour. Friendship Bench recommends a minimum of three sessions to be able to “experience the full benefits of the problem-solving therapy intervention.”

Friendship Bench says, “Sessions include screening for depression and anxiety, problem-solving talk therapy and behavioural activation-based support.”

Grandmother conducting a problem solving therapy session with a young female client on the Friendship Bench at a primary care clinic in Harare, Zimbabwe. Photo credit: Friendship Bench

Muzariri said more than 1000 mental health patients have been reached and have received counselling since the pandemic started, and the numbers are increasing each day.

“Before the pandemic disruptions, clients meet mental health experts in an open house for free counselling sessions. But because of the pandemic, we had to switch from our face-to-face problem-solving therapy to an online-based therapy,” she Muzariri said.

Muzariri said a client needs a mobile or digital device to call in and speak with a specialist to participate in the counselling session. 

Chibanda said Friendship Bench is successful “because these grandmothers are rooted in local culture,” he said.

“They use a language which the community can resonate with. So, I think the solution is to focus more on communities; to identify community leaders, people who can drive change at community level.”

Friendship Bench’s model has now been adopted across the continent and worldwide – Kenya, Botswana, Malawi, Zimbabwe, Zanzibar, New York as a Zimbabwean national treatment model in solving mental health issues. 

More countries have plans of adopting the approach. Chibanda said the goal is to help 5 million clients suffering mental health disorders, train 15,000 grandmothers and make the intervention accessible in communities around the world.

“That is really what I want to try and achieve, and it may sound very ambitious, but I would like to achieve this. It might not happen in my lifetime, but I certainly think it is achievable,” he said. 

Muzariri said the primary goal is to have a Friendship Bench within walking distance in every community in Zimbabwe.

Despite the successes of Friendship Bench, underinvestment in mental health interventions across the continent is a huge challenge. 

For instance, a 2017 study shows that less than 1 per cent of national health spending is allocated to mental health programs, with only one psychiatrist for every one million people. 

The WHO says 85 per cent of people with depression have no access to effective treatment.

Another challenge is that most mental health workers are based in urban areas.

In Zimbabwe, there are less than 20 psychiatrists for a population of more than about 16 million, Chibanda says. 

Chibanda wants this to change. “We can train ordinary people in communities to make a difference and reach out to other people in the community to help those who need support for their mental health,” he said. “This is how we solve this global problem.”

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