Mental Health America, an advocacy group, paints a bleak picture of psychological care in the United States. Almost 20 percent of Americans suffer from a mental illness, according to data from 2016, but more than half of these individuals never receive help. Barriers such as limited access to mental health care, the cost of treatment and a lack of insurance can affect a person’s ability to receive care.
Twenty-five percent of Americans in need of mental health care receive treatment from their primary-care physicians instead of from mental health specialists.
The Friendship Bench Project in Zimbabwe suggests that peer counselors may be able to help to fill this gap in health care.
In Harare and other cities in Zimbabwe, lay health workers known as “community grandmothers” meet with individuals struggling with depression, anxiety and trauma. Their meetings take place on wooden park benches outside health clinics.
According to the World Health Organization, depression affects at least 300 million people worldwide, while even more suffer from anxiety. Because of the high prevalence of these conditions, doctors refer to them as the “common colds of mental illnesses.” But unlike the cold virus, these disorders aren’t always remedied.
Similar to rates in the United States, anxiety and depression in Harare affect more than 25 percent of the population. They are the most common mental-health disorders in sub-Saharan Africa. Thirteen psychiatrists are available to treat Zimbabwe’s more than 14 million residents, making access nearly impossible for most.
The grandmothers in Harare were trained in problem-solving therapy through a project paid for by Grand Challenges Canada, a government effort to improve global health. All were educated elders, and most had experience in community health outreach. They also knew how to use a cellphone and lived near a health clinic.
Over nine days, the grandmothers were trained to help patients identify and solve their problems. The training covered such topics as mental disorders, counseling skills, problem-solving therapy and self-care, which is the ability to take care of one’s mental health and well-being.
Dixon Chibanda, a psychiatrist in Harare, co-developed the Friendship Bench program after finding that many people were hesitant to share their psychiatric troubles with a doctor; they felt safer disclosing their problems to a community member such as a trusted elder.
The grandmothers do not label their patients with a psychiatric diagnosis. Instead, they work toward solutions. Using indigenous terms rather than the scientific language of Western medicine, the therapy includes three parts: kuvhura pfungwa (opening the mind), kusimudzira (uplifting) and kusimbisa (strengthening). This approach is meant to eliminate shame and empower patients, helping them regain hope.
A study whose findings were published in December in the journal JAMA included 573 people struggling with anxiety and depression. Patients with suicidal thoughts, dementia, psychosis and late-stage AIDS were not eligible to participate, nor were pregnant and postpartum women.
The participants, almost all of whom were women, were divided into two groups. Half received the Friendship Bench intervention, which included six individual weekly sessions with a community grandmother. They also received group therapy. The other half received standard care, which included medication and advice from nurses.
The results suggest that park-bench therapy can heal.
Six months after the treatment ended, participants who received therapy from the grandmothers were one-third as likely as those who received standard care to have depressive symptoms. Their anxiety symptoms also improved.
Chibanda is hopeful that this intervention could fill mental-health gaps in other countries, too, including the United States.
“I’ve spent time in the United States, and I am familiar with the poor access to psychiatric care, particularly within inner cities and disenfranchised communities,” he says.
Peer support groups exist in the United States, but they are often for specific concerns such as addiction, eating disorders and alcoholism. Often, peer leaders don’t receive any mental-health training, and these groups operate separately from the hospital and health clinic setting, which makes referring a patient for treatment challenging.
Chibanda says American psychologists, social workers and psychiatrists could train people in the Friendship Bench model. He even suggests that the intervention could work in school systems because there often aren’t enough mental health services to meet every student’s emotional needs.
“This is a great community intervention,” says Traci Ruble, a psychotherapist in San Francisco who started a similar program, Sidewalk Talk, which offers people 15 minutes of free listening from a community volunteer who is also a trained psychotherapist. Unlike the Friendship Bench program, which provides patients with brief therapy, Ruble’s program serves as a bridge, identifying those who need additional psychological support and connecting them with community services.
While she was not involved with Chibanda’s study, Ruble believes this model could work in the United States.
“People crave human connection, and many of my volunteers want to share kindness and compassion with others,” she says.
Chibanda and his researchers are expanding their program to other parts of Africa. He hopes that this intervention becomes one of the most comprehensive mental health programs in sub-Saharan Africa.
“The benches can be set up in prenatal clinics, outside of doctor’s offices and inside of schools. The beauty of this intervention is its mobility. It takes healing outside of the doctor’s office so that it can happen anywhere,” Chibanda says.
Fraga is a psychologist and writer in San Francisco.