The Mental Health Crisis is Solvable

director of the African Mental Health Research Initiative. He's also one of only sixteen psychiatrists in the whole of Zimbabwe. Now that country has a population of thirteen million people. So Dixon Shabandah created the Friendship Bench that's a place for people to seek and access therapy for mental healths. These friendship benches are run by women in the community. They're fondly referred to as grandmothers, and their work is

proving hugely successful. It's even beginning to catch on around the world with a bench popping up here in New York and also throughout Kenya. We certainly need solvables like this because mental health is a global issue today and estimated three hundred and twenty two million people around the world live with depression, and the majority of those people

are in non Western nations. Now, mental health is fundamental to our collective and our individual ability as humans to think, to experience emotions, to interact with each other, to earn a living, and really just to enjoy life. In low income countries likes and bad Way, where seventy two percent of the population live below the poverty line, you can imagine that getting access to really any form of mental health therapy, it's not only difficult, it's nearly impossible. But

that's changing thanks to today's guest Dicks in Shabandah. You'll hear how in this conversation with Jacob Weisberg, I wanted to ask you what brought you to this problem? Well, the problem that I experienced, you know, as a junior psychiatrist in Zimbabwe, where I first started my work was just you know, quite huge, you know, just the sheer

amount of work and the need for professionals. And I realized from a very early stage that working from a hospital which just wasn't going to enable me to reach out to the thousands of people that needed care, particularly for depression. And when I lost a client of mine Erica through suicide, I realized the need to actually take mental health to the community, and this is how this

whole concept of working with grandmothers started. You know, a need to take evidence based mental health to the community and not just provided within health facilities or clinics. It's been a real struggle in this country, and I'm sure there's a different version of it Zimbabwe that you live through. But to put mental health on a par with physical health, people who will readily concede that everyone should have access to healthcare sometimes think that mental healthcare is secondary or

a luxury of some kind. Yeah, that is unfortunately a problem which is a global problem. A lot of people do not realize that by sidelining mental health you inevitably have challenges in addressing the physical health issues because coal morbidity is kind of the norm in a lot of chronic diseases. If you think of things like hypotension or diabetes, you know a lot of people who from these chronic

diseases do have core morbid mental health issues. And when you tackle just the physical and not tackle the mental health or the emotional well being or a person, you actually do not improve the outcomes or the physical aspect as well. So it's very important to have a very holistic approach. This is what the work that I do

is all about. You know, it's not really just about mental health, but it's ensuring that mental health results in improved outcomes of other conditions that people may have and functionality, for instance, the number of people who struggle in the workplace as a result of mental health issues. You know. Again, if you address the mental health issues, you improve people's functionality.

Organizations function better, companies produce better results, you know. So it's kind of endless if you think of the link of mental health with the challenges that are out there that the world is trying to address. What type of mental and emotional issues are you dealing with? How serious? So when we first started, our focus was on what we call common mental disorders, which in essence include things

like depression anxiety disorders PDSD. And we use an algorithm to enable us to determine the severity of the symptoms that a person presents with. And so if someone is, for instance, a red flag, someone is for instance, suicidal, the grandmothers on the bench will refer that person to

the next level. So we have these algorithms that enable us to address the needs of pretty much everyone who comes to the bench, either directly on the bench or by referring them to the next level, depending on what it is they present with, Jackson, How did you come up with this idea of the bench? So when I first made the decision to introduce something at community level,

a lot had been happening in my country. In two thousand and five, the country went through a lot of social or economic upheavals, and it was against the background of these upheavals that a need to introduce something at community level came. And unfortunately, because there were no psychiatrists or doctors available, I was instructed to try and come

up with a solution using community grandmothers. And because we couldn't use any of the buildings, we were also told, well, try and come up with something outside of the building. So it was really more of necessity, you know, and through an iterative process with the grandmothers, we eventually came up with the idea of actually delivering therapy on a bench. It was really necessitated by the fact that there was nothing, absolutely nothing, and so all I had with these grandmothers

and the idea of doing something on a bench. So, Dickson, you've seen the effectiveness of the friendship bench. Can you give us an example. Sure, let me give you an example of Derek. Derek was a young man who was employed in the tea industry in Zimbabwe and he was referred to the friendship bench after a third unsuccessful attempt to kill himself. And this was the first time really

he had the opportunity to tell his story. And when the grandmother invited him to share his story, he suddenly had this overwhelming sense of relief because he could really then share his story with the grandmother and that was, in essence, the beginning of his healing. Often it's simply about letting people share their stories. And after he shared his story, the grandmother worked through and enabled him to prioritize the things that needed to be done in order

to help him through the challenges that he was facing. See, Derek was living with HIV and he was struggling to get his medication. He was struggling to come to terms with being HIV positive. And that was his story. And today Derek is still functional and he's kept his job. Yeah, that is a great story. The grandmothers can't prescribe drugs. I'm assuming what do they do with patients who are

in need of some medical and intervention. Well, they refer so as I said earlier on, we have this algorithm and based on the severity of symptoms that a client presents with, they will then refer to the next level, and the next level will establish whether there's need for medication. If there's need for medication, the clinic nurse will prescribe the medication, not the grandmother or the psychiatrist will prescribe the medication. So the entry point into Friendship Bench is

a screening of basic symptoms for common mental disorders. For instance, the questionnaire will include questions related to sleep. You know, how have you been sleeping in the last week, and have you found it difficult to cope in the last week? Have you found yourself feeling tearful in the last week? Have you had thoughts of ending your life? Those kind of questions, And depending on the number of yes responses that the grandmother gets, she will then know where to

place a client. You know, whether this is a client that should receive the full Friendship Bench or they should immediately be referred because it's a red flag, So we try to use those categories to ensure that we really don't cause any harm to anyone through this intervention. So it's really an essence as stepped care kind of approach to addressing the treatment gap with a bulk of the client and so are taken care of by grandmothers and those that they can't help go to the next level. Dickson,

you said it's evidence based. What is the evidence that you have about how the effectiveness of this compares to other more conventional forms of initial treatment. Yeah, that's a great question, you know. So in the world of research, the gold standard for effectiveness is what we call the the randomized trial, and so we carried out a cluster randomized controlled trial of the Friendship Bench, which is actually

published in the Journal of the American Medical Association. And in this cluster randomized controlled trial, we had twenty four clinics that we're randomized into intervention arm, which was the Friendship bench or usual care, which essentially is being seen by a clinic nurse or a psychiatrist or receiving rozac

for depression. So that was one arm and we compared the primary outcome was HQ nine, which is a measure for depression symptoms, and we followed our clients over a six month period and after six months, our results showed that grandmothers were statistically much better than usual care, which include nurses and psychiatrists in alleviating symptoms of depression on the bench, you know, and so that evidence is published,

it's out there and people can look at it. But not only that, we have well over fifty peer reviewed publications about the Friendship Bench, how it works and why it works, both quantitative publications and qualitative publications which describe, you know, the process, which describe the experience of both the grandmothers and the experience of the clients. So the evidence is quite rigorous that we have managed to together

and publish over the past couple of years. There's often stigma attached to depression, and the stigma is different in different cultures. What's it like in Zimbabwe and how do you deal with that? So there's no difference in Zimbabwe with regards to stigma attached to different forms of mental illness. But the way we've dealt with it on the Friendship Bench is we have avoided the medicalization or the use of clinical terms to describe clients that come to the bench.

The first thing that we emphasize on the Friendship bench, for instance, is the desire for our team to improve a person's quality of life, and we do not refer to clients based on their diagnosis. And the other thing is we use local indigenous terms to describe what they're going through, like for instance, we would never use the

word depression. The term that is used on the Friendship bench in my language is kufungi sisa, which literally means thinking too much, and that often resonates with people when it comes to depression. When you think of the actual intervention itself on the bench, the different sessions we use language again which resonates with the community. We talk about kuvurap funga, which literally means opening up the mind. We talk about kusimud zera, which literally means uplifting, and then

we talk about kusimbisa, which is strengthening. You know, none of those terms are medical in whatever way you look at them, but they are very powerful and communities resonate with those words. They can identify with kuvapunga or opening up of the mind, because that's really what people want when they present their story. They want to open up their minds so they can see how through that story they can get healing. Through that story, they can get a sense of direction in terms of what needs to

happen in their lives. And again, if you look at New York City, they are pretty much doing the same thing. They are not labeling people, they are creating an opportunity for people to tell their stories. That's wonderful. And do you think that would apply as well in the developed world or is there something about traditional culture of the kind you were operating in a Zimbabwe and the role of grandmothers there that makes it specially effective. I think

it would apply in the developed world as well. What we've learned from Friendship Bench is that grandmothers are the custodians of local culture and wisdom, and using grandmothers in any culture is a great way of connecting people and really addressing some of the issues around, for instance, loneliness. You know, so, I think, as I said earlier on,

this model works and it's kind of universal. I think from what we're seeing in terms of, you know, the different places in the world that are using Friendship Bench. I also wonder, Dickson, is there something about doing this therapy out of doors as opposed to in a closed room.

That makes a difference to the patients. See from the feedback that we get from patients doing this kind of therapy, Outdoors almost kind of takes away the stigma that is associated with being indoors and seeing a therapist who is formally dressed or a psychiatrist. In fact, the name itself, you know, the Friendship Bench, just takes away the stigma. When we first started, you know, we actually called it

the mental health bench. And guess what, no one wanted to come to the mental health bench and the grandmothers, the grandmothers advised that I changed the name, change the name to Friendship Bench, because that's what really was happening. Yet, this was about creating friendship through stories. And when we change the name, you know, again it's it took away that that clinical aspect or clinical connotations, and it just

became a lot more acceptable. I think that one of the powers of Friendship Bench, whether you look at Friendship Bench in New York City, it's it's that it's outdoors, which gives people that freedom to express themselves. What's it like for the grandmothers? First of all, do they get paid and second of all, do they all take to it in the same way. I mean, I imagine that this is the kind of work that is on the one hand, very fulfilling, but on the other hand, very difficult,

including emotionally. For that. Yeah, it was one of our concerns, you know, a few years ago and a colleague of mine, Ruth, who is a clinical psychologist working on the friendship bench, she actually took it upon herself to try and look into how the grandmothers, you know, we're coping with doing all these work. So that was really her PhD topic to really look into how the grandmothers were managing to

do all this. Our hypothesis was, you know, we're probably going to see a lot of these grandmothers stressed, burned out, and they will they will themselves have very high rates of common mental disorders. But surprisingly, out of a random sample of hundreds of grandmothers, we found that the actual rates of common mental disorders amongst the grandmothers who were working on the friendship bench who was much lower than the community of people who were not working on the

friendship bench. And we then went deeper into it to find out how this was possible, and the themes that kept emerging from their grandmothers, you know, had a lot to do with altruism. Working on the bench for the grandmothers in their communities gave them a sense of purpose and over the years that sense of purpose, you know, resulted in mastery of a skill to really empower others in the community and help others in the community. And it also gave the grandmothers a sense of autonomy which

is very empowering. So in essence, the grandmothers are benefiting from this work while they help people. And are they paid and does that matter? So they do get an allowance from the city Health Department. I must say recently, the government of Zimbabwe this year finally after a long time, it decided to endorse Friendship Bench as a national program which is now integrated in the health system of the country.

So they do get an allowance. But we also get a lot of people who do Friendship Bench for free, who volunteer. For instance, we've taken Friendship Bench to schools. As you know, mental health issues are quite topical with young people. In fact, young people at the most affected

by depression. If you look at some of the statistics coming out of the world Health organization, and so we've been taking Friendship Bench to universities where we're introducing a peer driven Friendship bench where university students are trained to sit on the bench to provide the service to other students because Zimbabwe has one of the highest suicide rates in that part of Africa, and so we see this as an effective intervention where young people are reaching out

to provide support to other young people. And again it's all rooted in storytelling. You referred a little obliquely to what's happened in Zimbabwe, but obviously you have this devastating combination of long term political repression with economic collapse. Has that produced special circumstances or a larger number of people in need of this kind of cognitive therapy. So, while Zimbabwe is unique in the sense that it has a lot of problems, when you look at the global burden

of common mental disorders, it's not unique to Zimbabwe. The whole world is desperately in need of evidence based interventions such as Friendship Bench that really seek to narrow or reduce the treatment gap for these conditions so that everyone everywhere has access to this much needed help. So, yes, Zimbabwe has a whole lot of challenges. I mean historically, you know, if you look at Zimbabwe, it's a country

that is characterized by several generations of trauma. When you think of the right in the eighteenth century, the Pioneer Column, and then you had the Rhodesian Bush War, and then you had the massacre of more than twenty thousand debility speaking people. You know, the farm invasions where white folks were kicked off their farms and a lot of them killed. It's just a history of tragedy and with that history

comes a need for healing. And I see the Friendship Bench as a platform providing an opportunity for healing, not only for Zimbabwe, but for the world. And as I said earlier on, people thrive through storytelling, and we all have a story to tell. And if we can leverage our ability to use these stories to facilitate healing, I believe that we could be moving in a direction where the world becomes a better place for all of us.

And so, in a small way, that's what I believe in, you know, and that's why I keep carrying on doing this work on Friendship Bench. It's not just about mental health, it's about the big picture takes a news say in a small way, but not that small anymore. What's the scale of friendship Bench now in Zimbabwe and then everywhere else? So in Zimbabwe we are seeing thousands of people every month.

I mean in the last two years we reached out to over sixty thousand people, and we don't have accurate figures for places like Malawi, Zanzibar and Kenya where we've recently introduced. What we do know is friendship Bench New York City in the Bronx and Harlem is doing extremely well and they managed to reach out to over eighty thousand people a year ago, and so I guess the

numbers are growing exponentially. But what I really would like to see is a situation where friendship Bench is reaching out to millions of people across the world and also friendship Bench being recognized as a platform that really can enable people to open up and tell their stories in a safe environment, telling their stories so that we have healing. It's clear the idea of spreading around the world, But

what's next for the bench as a project. So as a project, we are now really looking at how we can reach our first million clients, not just you know, in Zimbabwe, but in the different parts of the world where we've introduced friendship Bench. We are about to introduce friendship Bench in Rwanda, we are planning to go to Liberia,

you know, we've just started in Kenya. And so what we're really working on is how to bring on board a digital component to enhance the work that the Grandmothers are doing because now we're really dealing with big data, and with big data, we need to really look at how best we can learn from the data that is being collected. How can we improve friendship Bench. How can friendship Bench continue to serve communities, How can friendship Bench

continue to improve lives across the world. So that's really our next big challenge. And for all of that, obviously we need support and we are we are looking for partners who can help us to really reach every corner of the world and make mental health, you know, evidence based mental health accessible for all. Well, that brings me to the last question I always like to ask, which is how can listeners advance this? How can they get involved?

How can they help? If you want to help friendship Bench, people can do is really within themselves in their communities, try to create space for healing. The world today is facing numerous challenges, numerous problems. You know, on the one hand, we have all these technological developments. You know, we've done so well technologically as a human race, but when you look at relationships, it's going the other direction. And one simple thing that we could all do is try to

create space for healing in our communities. Try to create space to listen to the stories that our neighbors have, the people in our neighborhood have, people in our communities. You don't have to be a psychiatrist or a clinical psychologist to make a difference in your community. You simply have to be able to give space for people to share their stories and you have to listen, and that

in itself is very very powerful. And of course, as Friendship Bench, we want to take Friendship Bench to every corner of the world, and so we're very happy to work with people to collaborate with people who feel that a Friendship Bench in their community or in their organization could help address mental health challenges or just generally improve the quality of life and make the world a bit of place. Dixon Shabanda, thanks for joining us Unsolvable Pleasure.

Thank you for having me. Wow Schka Saszina, he's a director of the Department of Mental Health and Substance Abuse at the World Health Organization said, when it comes to mental health, we are all developing countries, and that really stayed with me. And I think that this episode has been such a fitting last episode of this season of Solvable because communicating, talking, sharing, these are all proven to

potentially keep hopelessness at bay. And it's been such a privilege for me and I hope for you too to hear from all of our guests, each one of them a leading thinker, a leading doer, each one of them with their own Solvable and each one of them taking actions every day to solve the world's biggest problems. Thank you so much to them, and thank you too to our brilliant presenters over this series, Jacob Weisberg, Malcolm Gladwell,

Ann Applebaum and Ahmed Ali Akbar. And remember you can hear all thirty episodes wherever you get your podcasts, and you can learn more about solving today's biggest problems at Rockefeller Foundation dot org slash Solvable. We will be back with more inspiring conversations with brilliant problem solvers in twenty twenty. I'm May Higgins, Now go Solve It. Solvable is a

collaboration between Pushkin Industries and the Rockefeller Foundation. Produced by Laura Hyde, Hester Kant, Laura Sheeter, and Ruth Barnes of Talk and Blade. Pushkin's executive producer is Neil la Belle. Engineering by Jason Gambrell and the great folks at GSI Studios.

Research by cher Vincent, original music composed by Pascal Wise, and special thanks to everybody at Pushkin, including Maya Kanig, Maggie Taylor, Heather Faine, Julia Barton and Carlie Migliori, and to Christine Heenan, Rachel Roberts, Sierra Remersheed, and Rajiv Shah at the Rockefeller Foundation for making this series possible.