A legacy of poverty, genocide and dictatorship left Zimbabwe struggling with an epidemic of depression, colloquially known as kufungisisa, or ‘thinking too much’. Enter the Friendship Bench: a landmark project that employs grandmothers to deliver therapy in their neighbourhoods, which is coming to cities around the world. Up next? London
Would you like to share your story with me?” The elderly woman in the long yellow dress softly enjoins her companion: a slight man who sits with his head bowed towards his lap. It’s springtime in Zimbabwe’s capital city, Harare, and the setting, a simple wooden bench shaded by wild banana trees, makes for an unconventional therapy room.
Known as ‘gogos’ (elder women) or ‘ambuya utano’ (community grannies), these Zimbabwean community health workers (CHWs) have a record in treating mild to moderate anxiety and depression that beats many traditional talking therapies and pharmacological interventions. Meet the Friendship Bench grandmothers of Zimbabwe.
Founded in 2007, the Friendship Bench project has treated 280,000 people in its 16 years of existence, in 70 communities across Zimbabwe and at spin-off projects in Malawi, Kenya and most recently Zanzibar and Vietnam.
In 2024 it will arrive in London, with a series of Friendship Benches set to be installed in the city’s most marginalised communities.
“Whether it’s London, New York or Zimbabwe, everywhere the issues are similar,” Friendship Bench founder, Harare-based psychiatrist Dr Dixon Chibanda tells Positive News. “There are issues related to loneliness, access to care, and to just being able to know that what you’re experiencing – whether you call it stress or depression or anxiety – is treatable.”
Were it not for the tragic death of a young woman called Erica the project might never have come to pass. Late one evening in 2004, Chibanda received a call from a hospital doctor 100 miles south of his clinic in the capital: a 26-year-old who Chibanda had treated at his Harare hospital a few months earlier had attempted suicide. Chibanda talked to the young woman’s mother via telephone and decided that as soon as she was released from hospital, the pair would come to meet him to re-evaluate Erica’s treatment plan. A week passed, and then two more, with no word from the young woman. Finally, Chibanda received a call from her distraught mother. Erica had killed herself three days before.
“Why didn’t you come to Harare?” Chibanda recalls asking .“We had agreed that as soon as she was released, you would come to me…”
“We didn’t have the $15 bus fare to travel to Harare,” her mother replied.
It was a lightbulb moment for the Zimbabwean hospital psychiatrist, who had assumed that those in need of his help would be able to access care at his city clinic. “I knew then I needed to take psychiatry out of the hospital and into the community,” he explains. Chibanda also needed to achieve this feat in a country with a high level of stigma and superstition around mental ill-health, in which 70 per cent of the population live below the poverty line and where there were just 13 psychiatrists in a nation of 16 million.
According to the World Health Organization (WHO), more than 300 million people suffer from depression globally. It is the world’s leading cause of disability and contributes to 800,000 suicides per year, the majority in developing countries. In 2006, the year the Friendship Bench launched, Zimbabwe’s suicide rate was 20.1 per 100,000 population, twice the international average and one of the world’s worst records in a nation that has suffered a series of population-level traumas: from the five-year Gukurahundi genocide, to an HIV pandemic that saw 25 per cent of the population infected with the virus by 1997, and dictator Robert Mugabe’s 2005 campaign to forcibly clear slums (Operation Murambatsvina – ‘remove the filth’), which left 700,000 Zimbabweans homeless.
Elton Mudzingwa, 47, had hit rock bottom when his neighbour suggested he attend grandmother Felistas Gasa’s Friendship Bench in Harare. The street vendor had lost his wife and was struggling to cope with his grief at the same time as raising two sons alone. With his youngest son slipping into street drug addiction, father and son were no longer speaking, and Mudzingwa had begun to drown his sorrows with cheap beer. Mudzingwa arrived at his first session drunk, he admits.
“But grandmother was patient enough to speak with me,” he says. “She asked about my state of mind and if I was entertaining any suicidal thoughts.” As Gasa was a friendly neighbourhood face, Mudzingwa felt emboldened to open up. “I felt as if she cared for me, she was not telling me what to do or being judgmental,” he explains.
Gasa beams. “In the early days [of Friendship Bench], many of the people who came to us were stranded on the streets with their children [due to Operation Murambatsvina],” she says. “My work then and now was about changing lives as much as changing the way people look at their lives: a homeless woman might need advice on how to get funding to start a small business so she can return to her village with her children, for example.” Gasa feels happy when she sees lives change. “I think to myself: what if I had just ignored their story. Where would they be?” she adds.
The Friendship Bench method begins with talking therapy. Most of the therapists are older women, who are traditionally turned to for counsel in Zimbabwean culture. The women are trained in the basics of cognitive behavioural therapy [CBT] and allocated a park bench in their communities. They are paid a wage by the Zimbabwean Ministry of Health [equivalent to a community health worker’s wage], topped up by money fundraised by Friendship Bench. Referrals to the service, which come via primary healthcare, schools and police stations, and more recently self-referrals via social media, are screened via a validated questionnaire that’s couched in Zimbabwean concepts of mental ill-health: the Shona Symptom Questionnaire. Clinical cases, such as those at risk of suicide, are referred to hospital settings, with selected cases going on to receive two to four bench sessions. After these, clients are invited to join a peer support group for those who have received the Friendship Bench therapy (a circle kubatana tose or ‘holding hands together’ group), at which attendees are taught revenue-generating skills, such as making bags out of recycled materials.
Grandmother Juliet Kusikwenyu, 70 and based in Mbare [south of Harare], was recruited to the Friendship Bench from her job as a health visitor. It was Dixon Chibanda’s enthusiasm for community based mental healthcare that attracted her.
“He said that people are suffering from headaches and other symptoms but that the cause will be depression or stress,” Kusikwenyu says. “This made sense to me, and I wanted to help.”
Helping people solve their problems brings me so much joy
Integral to the Friendship Bench method is its articulation through local cultural concepts rather than western medical diagnoses, which can contribute to stigma. “Grandmothers talk in the sessions about kuvhura pfungwa, which is a Shona word for ‘opening up the mind’,” Chibanda explains, “they also talk about kusimudzira, a Shona word for ‘uplifting’ and kusimbisa, which means ‘strengthening’.”
Indeed the term ‘Friendship Bench’ was suggested by the project’s founding grandmothers, Chibanda adds. “Initially we called it the Mental Health Bench, but the grandmothers told me no one would want to come to a project with such a stigmatising name,” he says.
Kusikwenyu’s most memorable client was a young man called Samson, who came to the bench after finding out he was HIV positive. His diagnosis led to separation from his wife and he was left with three children and his elderly mother who had angrily rejected her son due to his HIV.
“I encouraged Samson and his mother to come to the bench together so they could both accept his [HIV] status,” Kusikwenyu says. “Then I urged him to get treatment for his condition and, when he started taking his medication, we looked at his stresses around providing for his three children.” With the grandmother’s counsel, Samson borrowed seed money to start a vegetable vending business. His business began to grow and today Samson is happily remarried to a woman he met at church who is also living with HIV. Now a tenant farmer, Samson has built a house for his family. “Stories like this bring me so much joy,” says Kusikwenyu. “It gives me the strength to work till I am 80!”
In 2016, Chibanda – collaborating with colleagues from Zimbabwe and the UK – published the results of a six-month-long randomised control trial in the Journal of the American Medical Association. They split 600 people with symptoms of depression into two groups and found that the group that saw the grandmothers had significantly lower symptoms of depression compared to the group that had conventional treatment.
To date there have been more than 100 peer-reviewed publications on the Friendship Bench, including a 2021 study which found that 67 per cent of women clients in Zimbabwe had maintained or expanded their income-generating projects, and another that found broad benefits in the model for grandmothers’ own mental health. An upcoming study, meanwhile, finds that the Friendship Bench improves the health outcomes of clients with diabetes and hypertension.
Lay-delivered mental health programmes such as the Friendship Bench have a range of benefits, says Dr Nilofer Naqvi, an academic psychologist who works in sub-Saharan Africa. They also hold lessons for expanding mental healthcare access to marginalised communities in the global north, including Indigenous peoples.
“With mental health carrying so much cultural belief and stigma, there are also genuine benefits in using interventionists, such as these grandmothers, who have an in-depth local, cultural knowledge and who are part of the community,” she says.
Yet there are risks, she notes. “[These programmes] can let health systems off the hook from investing in expert mental healthcare.” Naqvi worries about the emergence of a pool of lay mental healthcare providers in the global south “who are not equipped for the burdens they face in an absence of emergency psychiatry settings”, such as dealing with a violent psychotic episode.
Chibanda admits that there have been mistakes in translating projects to other contexts. While the Friendship Bench is thriving in Zanzibar, where the national Ministry of Health is scaling the project nationally, and in Vietnam with young people with HIV, a project in Jordan was wound down after government support failed to materialise, and in New York’s Bronx and Harlem after a sympathetic local administration was voted out. “Without local stakeholder buy-in we don’t have sufficient capacity or indeed local knowledge,” he says.
Grandmothers talk in the sessions about kuvhura pfungwa, which is a Shona word for opening up the mind
Friendship Bench packages as part of companies’ corporate social responsibility provision – offered by companies including Delta, First Mutual Life and Econet – have been criticised for offering slimmed-down versions of the model in settings not conducive to seeking mental health support: the Friendship Bench lite.
Chibanda, however, is unfazed. “We have helped almost half a million people in the past few years – and that’s actually not enough when you think of the magnitude of the problem and the care gap that exists,” he says, breaking off from negotiating his next rank of benches in London. “Our vision is to have a Friendship Bench within walking distance – everywhere.”
Mudzingwa, who is now sober and on good terms with his sons, warmly encourages fellow Zimbabweans who are suffering kufungisisa to give the Friendship Bench a try. “What do you have to lose?” he asks.
The light is fading in Harare as a grandmother takes up her position on the bench. “Would you like to share your story with me?” she asks. The man lifts his head.
Images: Cynthia Matonhodze and Costa Juta
Developing mental wealth is a series produced by Positive News and funded by the European Journalism Centre, through the Solutions Journalism Accelerator. This fund is supported by the Bill & Melinda Gates Foundation
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