Changing the Mental Health System from the Bottom Up: The Friendship Bench
“Bottom-Up” Implementation: The Friendship Bench
Worldwide, 80% of individuals with common mental illnesses reside in low and middle-income countries (LMICs), but LMICs, on average, allocate less than 0.5% of their national budgets on mental healthcare, while high income countries typically spend over 5% (1,2). In most LMIC settings there is a profound lack of mental health policy development and implementation to address the significant need for mental healthcare (1). Barriers to improving access to quality mental health services in the African region include the lowest per capita mental healthcare spending and lowest average number of working mental health professionals among all WHO regions (2). Energy is often focused on local, regional, or national-level policies in order to establish long-term, wide-spread change for mental health treatment. International organizations like the World Health Organization (WHO) and the United Nations (UN) aim to assist in the development of such policies in LMICs. Whereas community mental health services exist in many parts of the world, the range of available interventions may be limited, particularly in LMICs. Innovative approaches to community-based care are seldom scaled up to a regional or national scale (3). Programs that begin at the community level and are expanded are often known as “bottom-up” changes, whereas national-level policy changes that gradually change community-level systems are known as “top-down” changes (4). Although “bottom-up” change is difficult to achieve, examples of success do exist. Community-based mental health interventions such as Zimbabwe’s Friendship Bench program have gained national or international notoriety, expanding beyond the community in which they were first developed and changing mental health treatment on a regional, or national scale.
The Friendship Bench: A Community-Level Solution Expanded
The Friendship Bench is a problem-solving therapy intervention in Zimbabwe developed by Dixon Chibanda in the early 2000s (6). The Friendship Bench is scaling up in Zimbabwe and has become widely known as a success story among low-cost, community-level mental health programs (7). In developing the Friendship Bench, Chibanda took local healthcare system contexts and cultural perceptions of common mental illnesses into account, developing a therapy treatment that could be provided by community health workers without previous training in mental health and use culturally appropriate terminology (such as the Shona words for emotional distress that are closest to “depression” and “anxiety”) to treat common mental illnesses. The program relies on lay counselors who are mostly older women to screen and give therapy sessions to people with symptoms of emotional distress or common mental illnesses at primary care facilities (8). With six structured therapy sessions given on a bench on the primary care facility grounds, the Friendship Bench serves as a non-threatening and stigma-fighting treatment option in an area with very limited options for outpatient mental health services (8).
A key to the success of the Friendship Bench is the ability to operate successfully within Zimbabwe’s cultural perceptions of mental health and the country’s primary care system. The Friendship Bench now has a website, a training manual, international news coverage, and is the subject of 9 (and growing) academic research articles since 2011. What started in a few facilities in Harare now has been scaled up to 72 clinics in the cities of Harare, Gweru, and Chitungwiza, serving a region with 1.8 million people (8). In the 20 years since the program was initiated, over 40,000 people have accessed mental health treatment in Zimbabwe through the Friendship Bench (8). In a country with less than 1 psychiatrist for every 1 million people (for comparison, the United States has about 105 psychiatrists for every 1 million people), a mental health program such as the Friendship Bench fills a significant gap and provides vital care for common mental illnesses such as depression and anxiety (7, 9). The program’s simplicity and success in Zimbabwe have inspired numerous similar initiatives in other countries, including school-based peer counseling programs in the United States and a 2018 launch of a Friendship Bench program in New York City by the office of Mayor Bill DeBlasio and the New York City Health Commissioner Dr. Mary Bassett (10).
A Model for Change
Many other LMIC or low-resource settings have gaps in mental health care professionals similar to that of Zimbabwe. The Friendship Bench is part of a growing group of mental health programs that have shown that trained lay counselors can provide quality care for common mental illnesses in these areas, both in low-income and high-income countries (11). The Friendship Bench in particular shows what can happen when treatment successes are demonstrated, stakeholder partnerships are strong, and integration into the public system is successfully achieved. Lay counselors in the Friendship Bench program in Zimbabwe are employed by city health authorities, which facilitates scale-up to other cities and shows policy-makers around the world that such a program is an inexpensive and effective treatment option that city, state, or national governments can implement (11). Not all widespread change to mental health treatment is achieved from national-level policy change, but community-level successes in treating mental health conditions in an inexpensive and efficient way have the power to spread not only throughout a health system in an LMIC setting but to communities and governments around the world.
References
- World Health Organization. (2008). The global burden of disease: 2004 update. Geneva, Switzerland. www.who.int/healthinfo/global_burden_disease/2004_report_update/en/
- Woldetsadik, MA. (10 March 2015). Mental Healthcare in Sub-Saharan Africa: Challenges and Opportunities. The RAND Blog. https://www.rand.org/blog/2015/03/mental-healthcare-in-sub-saharan-africa-challenges.html
- Erasmus E. (2014). The use of street-level bureaucracy theory in health policy analysis in low- and middle-income countries: a meta-ethnographic synthesis. Health Policy and Planning, 29:iii70–iii78. DOI: 10.1093/heapol/czu112
- Walker L, Gilson L. (2004). ‘We are bitter but we are satisfied’: nurses as street-level bureaucrats in South Africa. Social Science and Medicine, 59: 1251-1261. DOI: 10.1016/j.socscimed.2003.12.020
- World Health Organization. (2017). Mental health atlas. Geneva, Switzerland.
- https://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/
- World Health Organization. (2018). Bulletin of the World Health Organization. Geneva, Switzerland. 96:376-377. doi: http://dx.doi.org/10.2471/BLT.18.030618
- The Friendship Bench- Zimbabwe. (2019). Harare, Zimbabwe. https://www.friendshipbenchzimbabwe.org
- Mental Health Innovation Network (2019). Innovations: The Friendship Bench. London, UK. https://www.mhinnovation.net/innovations/friendship-bench
- World Health Organization. (2019). Global health observatory (GHO) data: Psychiatrists and nurses (per 100,000 population). Geneva, Switzerland. https://www.who.int/gho/mental_health/human_resources/psychiatrists_nurses/
- The Friendship Bench-Zimbabwe (2018). Friendship Benches in New York City! A south-north knowledge and experience transfer. Harare, Zimbabwe.
- Chibanda, D., et al. (2015). The Friendship Bench programme: A cluster randomized control trial of a brief psychological intervention for common mental disorders delivered by lay health workers in Zimbabwe. International Journal of Mental Health Systems, 9:21. DOI 10.1186/s13033-015-0013-y
Spotlight: Rukudzo Mwamuka, MBCHB
Bio: Rukudzo Mwamuka, MBCHB is a 3rd year M.Med student at University of Zimbabwe, where she also obtained her undergraduate Bachelor’s in Medicine/Surgery degree and postgraduate Diploma in Mental health. Rukudzo’s passion in mental health research and community psychiatry has led her to work with the Friendship Bench Trust, an organisation that works with lay health workers to provide psychological intervention in an effort to close the huge treatment gap in Zimbabwe.
Q: Can you tell me a little about yourself?
A: I am in my final year of the psychiatry residency program at the University of Zimbabwe. I was drawn to the field of psychiatry during my undergraduate rotation when I got to realize how mental health treatment was holistic taking into cognizance one’s social, cultural and spiritual circumstances. I also got to work with Professor Dixon Chibanda, the founder of the Friendship Bench, whose work really inspired me. Personally, I am a very sociable person and I would like to think of myself as very motivated and self-driven. I am married and have two wonderful daughters. I also love traveling and experiencing other cultures.
Q: How did you first get interested in Global Mental Health?
A: In Zimbabwe, there are very few psychiatrists, and the career pathway in psychiatry did not seem well defined to me. My love of various cultural experiences led me to develop the interest in Global Mental Health. I was curious to know to what extent cultural differences had an impact on mental disorders
Q: Can you tell us a bit more about the Friendship Bench?
A: The Friendship Bench was Professor Dixon Chibanda’s baby and was born from necessity before growing into the intervention it is today. In 2005, the Government of Zimbabwe destroyed illegal homes, leaving thousands of people homeless overnight. People were psychologically traumatized from losing everything they owned overnight. Unfortunately, there was only a handful of psychiatrists and psychologist to offer support during this crisis. Professor Chibanda began to work with 14 community lay health workers already integrated in the communities to meet this need for mental support. The lay health workers were trained to screen for common mental illness and to do problem-solving therapy. Since the Friendship Bench intervention was spearheaded by lay health workers, they used the Shona Symptom Questionnaire 14 (SSQ14) a screening tool for common mental disorders that was developed locally and utilizes the local idioms that are used to describe anxiety/depression in our community. From the results of the questionnaire, the community health worker can determine whether the patient needs to be referred for further psychiatric care or if subsequent sessions with the health worker would be beneficial.
Q: What does a typical friendship bench process look like?
A: First, the patient either comes to the Friendship Bench or is referred by the primary care facility they go to. Then the lay health workers, typically grandmothers in the community, take the patient to a bench in a discrete location on the clinic grounds where they sit and talk. The grandmothers administer the culturally sensitive questionnaire, the SSQ14, and patient attends 6 sessions in the following weeks. During these sessions, they work with the community health worker to go through a therapeutic process called “kuvhura pfungwa” which literally translates to opening the mind, where the patient goes through problem-solving therapy. After the completion of their sessions, the patient is referred to a support group that is called Circle Kubatana Tose, which means coming together. This support group involves the patients sitting around in a circle and discussing their problems while making crafts. Everyone gets a chance to speak, and the crafts are then sold and the profit split among the participants, giving them a little bit of financial freedom. The patients who have red flags on their initial SSQ14 score or who do not improve after the 6 sessions are referred to a professional mental health worker.
Q: What were some of the challenges in creating the Friendship Bench?
A: The first challenge that the Friendship Bench had to overcome was finding funding, but this has been largely overcome thanks to various grants and donations. The second challenge was the acceptability of the program. Initially, there was concern that it would not be accepted, but the fact that the lay workers were already well respected and trusted as wise advice-givers really helped in overcoming this challenge. Now the primary challenge is scaling up the Friendship Bench to different populations. The Friendship Bench is an intervention that is being rolled out throughout Zimbabwe’s urban and rural areas and among other countries such as Malawi and Zanzibar.
Q: How do you see your work in mental health connecting with your daily life?
A: I think my work is very connected to my life. I realized that taking care of your mind and emotions is something that is important no matter your mental health status- mental health awareness is something we always need. Psychiatry taught me good self-care and how to take care of other people without burning myself out. It taught me that sometimes giving a smile or asking how someone’s day is can make a huge impact. There is still a stigma against mental illness and a résistance to mental health care; however, I feel that fixing the mind is important. Even after physical health is attained, you still need to attend to your mental health.
Q: If you could travel anywhere in the world without having to worry about funding, work, or language barriers, where would you go?
A: I would probably go to South Korea. I am drawn to South Korea for its rich history and vibrant culture. It has a good balance of nature, vibrant tech industry, amazing food and great shopping malls as well. Ultimately though, I think the part of Korea that draws me towards it the most is the emphasis their culture places on family, something that is very important in my own life as well.