In conversation Charmaine Chitiyo from the Friendship Bench
The Friendship Bench is a Non-Governmental Organization (NGO) born in Zimbabwe that aims to provide evidence-based psychological interventions at a community level that are, accessible to everybody. The organisation provides mental health support through trained community health workers at primary health care and community levels. These community health workers offer the possibility of meeting on public benches to support and assist people in need of mental health care.
Can you maybe first introduce yourself and tell us a bit about you and your role in the Friendship Bench, about the work you do here and how this organisation came about?
My name is Charmaine Chitiyo. I am the program manager for Friendship Bench. I started with the organization in 2018 by leading one of the research programs that was taking place at the time. As the program manager, I coordinate the implementation of the Friendship Bench in all of Zimbabwe. My role is to support the teams working on the ground and make sure that the structures are in place to ensure that activities are implementated.
Friendship Bench is an evidence-based, mental health intervention which started in 2006 by Professor Dixon Chibanda. The main objective of this intervention was to bridge the gap in mental health provision in Zimbabwe. At that time, there was very little or no access to mental health services or professionals at a community level. And where support was available , mental health services were very expensive. As you may know, and this is maybe not just for Zimbabwe, meeting a psychiatrist or psychologist can be very expensive. At the same time, there were very few professionals in this field in our country. This is still the case in the present. I think we’re sitting at about 18 professionals for the whole country. So, for people to access mental health services at the time, it was a struggle. Professor Chibanda was working in one of the health facilities in the capital and people would come presenting with mental health problems and wanting to get mental health services, but the services were not available or at least the access to health care workers was missing.
He then realized that there was a gap and experienced a client who took their life before they could complete the service delivery cycle. He then realised that there was a need for a community mental health intervention where people could access mental health within their communities, and where they could have someone to talk to when they had problems. So that’s when the Friendship Bench started.
It started with what we referred to as community health workers who are often called grandmothers or grandfathers. These are people who have been engaged by the Ministry of Health as health promoters within their communities. These people are there, within the communities, to give the support “on the ground”. They do follow-ups and home visits. They check on clients who are on treatment for different kinds of conditions etc. Professor Chibanda realised that these actors were the best-suited cadres for this task because they had been in their communities for a long time and understood the problems that communities were facing. So he set up trainings for them to be able to deliver a simple therapy called “problem solving therapy” to people in their communities. This means that someone can come and sit on the bench with a grandmother, or grandfather, and be able to talk about their problems and find ways to identify solutions. In this sense, it is more of a curative approach that aims to identify people at risk, identify their problems and find ways to deal with these issues at an early stage and before they develop severe mental health condition that would require more specializd care. So that’s how the intervention started. Nowadays the intervention has grown and is functioning in all 10 provinces of the country. Our vision now is to have a Friendship Bench within walking distance for all. This would mean that wherever you are, someone is there to talk to you if you need to talk to someone.
The intervention is made of two parts, the first one is the therapy which is one-on-one and involves the user and the grandmother or the grandfather to talk about your problems. The idea is to be able to talk and identify solutions over a period of time until the person feels ready to go his or her way.
Then we have what we call “Mental health support groups” referred to as “Circle Kubatana Tose” (CKT), meaning holding hands together, which is an extension of the program that is offered to people who’ve come for the one-on-one session so that they don’t relapse, or they don’t go back to their problems. On these support groups they get to meet 10 to 15 people, assisted by the grandmother/s, that can sit together once a week for an hour and just talk about their problems and share experiences. In many cases, these groups also became income-generating groups because this was one of the main problems that had brought people to the intervention in the first place: How to get money to send their kids to school? We noticed that another set of issues such as gender-based violence was also connected to lack of income.
As I mentioned before, the intervention has evolved from its origins, and it doesn’t only rely on grandmothers. We now have what we call “youth buddies” who are young people between the ages of 16 and 25 who are now offering the service to other young people. We realized young people are sometimes afraid of going to older people to talk about their problems and they also hardly visit health facilities. So, after doing some research, we learned that young people would rather talk to people in their age group as they will be the best fit to understand their language and the dynamics around their lives.
Who are the users of the service? Is there a specific demographic that uses it?
We have many different users from across demographics. But generally speaking, the people who come to the clinic, and use the Friendship Bench are between the ages of 25 and 45, that’s the biggest group. But we also have people even in their 50s and 60s. We also see that users are mostly female. That’s very apparent. One of the first things we realized was that women are the ones who visit health facilities, either for their own treatment or because they are caregivers which means that they spend a lot of time caring for others. Since they are the ones visiting the health facility, they access these services more. Men don’t show health-seeking behaviour in the same way as women and also, they very rarely visit the health facility. This makes it harder for us to reach out to them. We are trying to target this by extending the interventions to the communities and bringing the services to places different than health facilities but we’re still seeing more women as users. I guess generally women are more open to talking about their problems and they are more involved in community spaces and meetings which means that they have access to all this information.
Where are the benches usually placed? Are they always located outside of a healthcare facility?
Yes, they are typically placed within the grounds of a health care facility.. We place them outside in a discreet location where there is no distraction, away from the buildings. The idea is to place them somewhere where people feel safe to talk about their issues without worrying that someone would hear them. This is a more friendly environment and it’s not too structured. When you’re in a room, there are a lot of things that can deter you from opening up because it’s just a structured space. We’ve also set them up at our offices and we have a few that are placed in universities as well. But the structure is the same.
Why did you decide to use urban infrastructure (benches) for providing mental health care? Why did you decide to use public urban infrastructure instead of, for instance, building health care facilities or offices?
Like I said earlier, a lot of people have a certain attitude towards treatment within a closed space. The idea of being in a room means there are certain ways in which the service is going to be delivered. Someone will be sitting on the other side of the table; they will be asking you questions and you will have to follow instructions. A lot of people are not comfortable with this dynamic. At the same time, the setup of a room doesn’t provide a lot of privacy because anyone can hear what you’re talking about, depending on how the room is structured. Consultation rooms are designed often in a way in which there will always be people sitting outside waiting to come in for the next session. There is therefore a high chance that someone might not feel comfortable opening up in this context or even thinking about going there.
But the benches, because they are outside, under a tree, in a more secluded and safer place, we felt that people would feel comfortable to talk about anything. They can cry and really show their emotions without worrying that someone else will see them and it is also a more relaxed environment to dive into these difficult topics. It’s therapeutic to be out breathing fresh air, hearing the birds sing, and feeling the wind blowing. For the delivery agents, it is also more comfortable to meet their clients outside. There is a lot of stigma around mental health treatment you know? being seen entering a room, especially one designed to talk about your problems can be challenging for many. Lastly, the context of sitting out in nature gives privacy in the sense that no one will make assumptions about what you are talking about with the grandmother because it could just be like a meeting with a friend. This puts people at ease and helps them feel comfortable and share.
What role does care play in the work your organisation does? How do you work towards a more caring community?
Care it’s probably the basis of what the intervention is about. The whole service we provide is wrapped around care. We care about people’s need for services, we care about people’s privacy, and we care about people’s recovery. We do follow-ups with our clients; we want to make sure that if they present some symptoms that they receive further care. So, caring, for me, starts from the beginning. Some of our grandmothers have experience with clients who come and just cry the whole hour. So just being able to cry and talk will maybe not solve all your problems, but it can be therapeutic. And as long as someone cares about them, then that person doesn’t feel like they’ve wasted time.
From the beginning, we show them that we care about our clients. And then again, the aspect of the continued support through the community and entering health support groups, for us that’s an aspect of care on its own because we’re no longer limiting the care to us as the service provider. Instead we are saying: “let’s allow the care to also come from other clients who may have experienced the same problem or are also going through their problems”. If you’re sitting in a group, you can offer each other care. Even beyond the group, we’ve seen other clients who have even visited each other outside the group and created their own networks. I feel like the whole process itself is centred around caring for the present that we are working with.
Recently, we have also partnered with another organization that is looking into caring for the people that are delivering the service and also need to be cared for. This came about during COVID-19. We realized that most of the nurses, most of the health care workers, including our grandmothers would spend a lot of time focusing on trying to raise awareness and help support families. They would also be exposed to people who have tested positive for the virus so they would sometimes be excluded from their social groups because of fear of getting infected. We realized that no one was thinking about this. The carer was expected to always be there to care for others. We started working with the “Caring of the Carer”. Thus, that’s another aspect of care that we’ve introduced which means that we are not only caring for the clients, but we are also caring for our service providers. We have an open free line where you can get therapy anytime you need it. You can also get what we call self-care material. In this sense, it’s not just care from one person to the other but even care for your own wellbeing.
If you would like to read more about how the Friendship Bench initiative came about you can take a look at this Ted talk featuring the NGO´s funder, Dixon Chibanda. If you are interested in learning more about the work being done at the Friendship Bench, please visit their website where you can find more about their approach to community-based mental health care and find many resources. You can further explore the ongoing research published on the outcomes of the Friendship Bench program here.
