Dixon Chibanda: How Can A Team Of Grandmothers Make Therapy Accessible To All? In Zimbabwe, like many countries, there are few options for mental health care. So psychiatrist Dixon Chibanda came up with an unexpected solution: therapy from trained grandmothers, on park benches.
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Dixon Chibanda: How Can A Team Of Grandmothers Make Therapy Accessible To All?

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Dixon Chibanda: How Can A Team Of Grandmothers Make Therapy Accessible To All?

Dixon Chibanda: How Can A Team Of Grandmothers Make Therapy Accessible To All?

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GUY RAZ, HOST:

So one of the reasons why it can be so hard to erase the stigma of mental illness is that, no matter where you are in the world, there are not enough doctors to treat it. And in some places, it's a lot worse than in others.

So let's just talk about Zimbabwe for a moment. What is the - what is the state of things with respect to mental health care? I mean, first of all, there are not many psychiatrists in the whole country, right?

DIXON CHIBANDA: No. At the moment, we have 15 psychiatrists. So it's essentially a ratio of one psychiatrist to just over a million people.

RAZ: Wow.

CHIBANDA: And that ratio is pretty sort of standard across Africa and a lot of other low and middle-income countries. Zimbabwe has one of the highest suicide rates in this part of the world.

RAZ: This is Dr. Dixon Chibanda, one of Zimbabwe's only psychiatrists.

CHIBANDA: So the treatment gap, as we call it when we use our jargon, is massive in Zimbabwe and a lot of other African countries.

RAZ: I mean, is it because there's more of a priority on other kinds of medical care, like physical ailments that are not mental ailments?

CHIBANDA: Yeah, definitely. There's a lot more emphasis on infectious diseases - you know, when you think of things like HIV infection or tuberculosis, maternal and child health - because they tend to be a lot more conspicuous than mental, neurological and substance use disorders, which are sometimes seen as, quote-unquote, "social challenges," you know.

(SOUNDBITE OF MUSIC)

CHIBANDA: And that's the reason why we don't really have many psychiatrists, not only in Zimbabwe, but the world over. The stigma, the lack of awareness about mental health issues, this is a global problem.

RAZ: Now, Dixon had always been aware of this treatment gap. But it didn't really hit home for him until about 15 years ago, when something happened that would change his entire career. Dixon explains more about it from the TED stage.

(SOUNDBITE OF TED TALK)

CHIBANDA: One evening while I was at home, I get a call from the ER from a city which is some 200 kilometers away. And the ER doctor says, one of your patients - someone you treated four months ago - has just taken an overdose. So as best as we could over the phone with a ER doctor, we come up with an assessment. You know, we ensure that suicidal observations are in place. We ensure that we start reviewing the antidepressants that this patient has been taking.

And we finally conclude that soon as Erica (ph) - that was her name, 26-year-old. As soon as Erica is ready to be released from the ER, she should come directly to me with her mother. And I will evaluate and establish what can be done. And we assume that that will take about a week. A week passes. Three weeks pass. No Erica.

Then one day, I get a call from Erica's mother. And she says Erica committed suicide three days ago. Now, almost like a knee-jerk reaction, I couldn't help asking, but why didn't you come to Harare, where I live? We had agreed that as soon as you're released from the ER, you will come to me. Her response was brief - we didn't have the $15 bus fare to come to Harare.

Now, suicide is not an unusual event in the world of mental health. But there was something about Erica's death that struck me at the core of my very being. That statement from Erica's mother made me realize that it just wasn't going to work, me expecting people to come to me. And I got into this stage of soul-searching, trying to really discover my role as a psychiatrist in Africa. And after talking to colleagues, friends and family, it suddenly dawned on me that actually one of the most reliable resource we have in Africa are grandmothers. Yes, grandmothers. In every community, there are hundreds of them. And they don't leave their communities in search of...

(LAUGHTER)

CHIBANDA: ...Greener pastures.

(LAUGHTER)

CHIBANDA: See, the only time they leave is when they go to a greener pasture called heaven.

(LAUGHTER)

CHIBANDA: So I thought, how about training grandmothers in evidence-based talk therapy, which they can deliver on a bench?

RAZ: So, Dixon, I guess more than ten years ago, you came up with this program that you call the Friendship Bench. What exactly is it, and how does it work?

CHIBANDA: So in very simple terms, the Friendship Bench is really - literally a bench which is used to create space for healing. So I work with grandmothers - community grandmothers, who are trained in basics of cognitive behavioral therapy. That's just a form of therapy which is often delivered by highly-skilled professionals such as clinical psychologists and psychiatrists.

So what I did in 2005 was I trained a whole lot of grandmothers to deliver this intervention. And when you looked to this part of the world, grandmothers are considered to be the custodians of local culture and wisdom. And they are rooted in their communities. And they have this amazing ability to listen in a very empathic way. They have this amazing ability to be attentive. And I think they are such an amazing resource.

RAZ: I'm curious. I mean, the Friendship Bench is a - from what I understand, is a public bench. It's out in the open. Is that - I mean, it seems unusual - right? - because most of the time when people go to therapy, they do it in a private place. There's a white noise machine. You know, there's a privacy screen so you don't see other patients. But this is happening out in the open, right?

CHIBANDA: Yeah. It's in the open. And when we first started, you know, we would put the benches in discrete areas in the community, you know, outside the clinics. But with time, I realized people don't mind where the bench is. And I think it's because the bench is associated with the community. And the grandmothers, as I say, are a source of wisdom. And they are seen as a person that you can go to not just for your mental health issues.

You know, although our focus is mental health, people will come for all sorts of - all sorts of problems. And, you know, I'll tell you a little story. When we first started, we're not - you know, typically - me being a psychiatrist, when we first started I thought, OK, we need to call this bench the Mental Health Bench. And, of course, no one came to the Mental Health Bench.

(SOUNDBITE OF MUSIC)

CHIBANDA: You know, but the minute we changed the name to Friendship Bench, people found it a lot more appealing. So again, it's all about how you deliver it. You know, in a way, that enables people to actually find your program or intervention user-friendly.

RAZ: In just a moment, we'll hear more from Dixon about the grandmothers of the Friendship Bench. On the show today, ideas about Erasing The Stigma. I'm Guy Raz. And you're listening to the TED Radio Hour from NPR.

(SOUNDBITE OF MUSIC)

RAZ: It's the TED Radio Hour from NPR. I'm Guy Raz. And on the show today, ideas about erasing the stigma of mental illness. And we're just hearing from Dr. Dixon Chibanda. He's a psychiatrist in Zimbabwe who trains community grandmothers to deliver talk therapy on park benches throughout the country. Dixon described one of these interactions from the TED stage.

(SOUNDBITE OF TED TALK)

CHIBANDA: Farai (ph), a 24-year-old mother of two, walks towards a park bench. She looks miserable and dejected. Now, on the park bench sits an 82-year-old woman better known to the community as Grandmother Jack (ph). Farai hands Grandmother Jack an envelope from the clinic nurse. Grandmother Jack invites Farai to sit down as she opens the envelope and reads. And after a long pause, Grandmother Jack takes a deep breath, looks at Farai and says, I'm here for you. Would you like to share your story with me?

Farai begins, her eyes swelling with tears. She says, Grandmother Jack, I'm HIV positive. My husband left me a year ago. I'm unemployed. I can hardly take care of my children, tears now flowing down her face. And in response, Grandmother Jack moves closer, puts her hand on Farai and says, Farai, it's OK to cry. You've been through a lot. Would you like to share more with me?

And Farai continues. In the last three weeks, I have had recurrent thoughts of killing myself, taking my two children with me. I can't take it anymore. There's an exchange between the two which lasts about 30 minutes. And finally, Grandmother Jack says, Farai, it seems to me that you have all the symptoms of kufungisisa (ph). The word kufungisisa opens up a floodgate of tears. Kufungisisa is the local equivalent of a depression in my country. It literally means thinking too much.

We define depression using appropriate local idioms of distress that people can identify with. In other words, the Friendship Bench is all about immersing ourselves in the experiences of the communities that we are serving and finding out what it is. How do they articulate the whole concept, the whole construct of depression? And once you pick that up, people do realize that this is indeed a medical condition. And the interesting thing is we've introduced Friendship Bench in New York City in the Bronx and in Harlem. And the issues that come out in New York City are no different from those that are coming out here in Zimbabwe. You find it across the globe.

(SOUNDBITE OF TED TALK)

CHIBANDA: Today, there are hundreds of grandmothers who are working in more than 70 communities. And in the last year alone, more than 30,000 people received treatment on the Friendship Bench from a grandmother in a community in Zimbabwe.

(APPLAUSE)

CHIBANDA: And our results show that six months after receiving treatment from a grandmother, people were still symptom-free - no depression, suicidal ideation completely reduced. In fact, our results - this was a clinical trial. In fact, this clinical trial showed that grandmothers were more effective at treating depression than doctors.

(LAUGHTER)

CHIBANDA: They...

(APPLAUSE)

CHIBANDA: And so we are now working towards expanding this program. There are more than 600 million people currently aged above 65 in the world. And by the year 2050, there'll be 1.5 billion people aged 65 and above. Imagine if we could create a global network of grandmothers in every major city in the world who are trained in evidence-based talk therapy, supported through digital platforms, networked. They will reduce the treatment gap for mental, neurological and substance use disorders.

RAZ: I mean, it is such a small nudge, this whole idea. But it has such an enormous impact.

CHIBANDA: It does. Indeed, it has an enormous effect. And yet, when you come to think of it, it's very simple. There's nothing much to it (laughter). You know, a one-month training, a wooden park bench, a grandmother, and that's it. You're in business.

RAZ: That's Dixon Chibanda. He's a psychiatrist and the founder of the Friendship Bench. You can find his full talk at ted.com.

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