Right, good afternoon everybody.
So, I come from Zimbabwe, a country which
is often characterized by several decades
of psychological trauma, from the Rhodesian
Bush War, the farm invasions, the massacre
of more than 20,000 people in Matabeleland,
and so the Friendship Bench is in essence
a program that was conceived as a result of
one such traumatic piece of history from our
country, which actually started on the 19th
of May in 2005, when the Zimbabwean government
at the time, under the leadership of Robert
Mugabe, embarked on a cleanup operation which
was called Operation Murambatsvina, which
literally means "Removing the filth."
And what Operation Murambatsvina was all about
was a systematic destruction of buildings,
structures that were labeled by the government
as illegal, whatever that meant at the time,
and it resulted in over 700,000 people being
left homeless, and according to the United
Nations, over two million people were psychologically
affected as a result of this operation.
During that time, I was studying for my Master's
in Public Health, and I was instructed to
carry out a survey to establish what the prevalence,
or the magnitude of the psychological morbidity
was, and when these results were presented
to the authorities, I was then told, "You
need to really come up with some kind of intervention."
A whole lot of things were happening at the
time, and of course in a country where there
were absolutely no resources, and all the
professionals, most of them had left.
I was in essence given a group of grandmothers
to work with, 14, to start a program, or pilot,
something that would eventually help thousands
of people, and it was pretty depressing initially,
you know?
And anyway, to cut a long story short, through
an iterative process with these 14 grandmothers,
we gathered as much information as we could
about programs that had been developed in
the country, outside the country, and we essentially
through this iterative process tested different
approaches, you know, which were obviously
rooted in cognitive behavioral therapy.
And over a couple of months, we managed to
come up with a meaningful sort of intervention,
and over the years we developed a series of
components to this intervention, which became
known as the Friendship Bench, which in essence
is psychological therapy which is delivered
on a bench in the community by grandmothers.
And one of our most recent publications is
a clinical trial of this intervention, where
we compared the Friendship Bench with usual
care, through a cluster randomized controlled
trial, and the cluster randomized controlled
trial, which is published in the Journal of
the American Medical Association actually
showed that grandmothers were more effective
at delivering and alleviating symptoms of
depression and averting suicides than usual
care.
And usual care included, you know, nurses
trained in mental health, psychologists, and
also the use of Prozac, so grandmothers were
pretty effective at doing their job.
And to actually illustrate what we've achieved
over the past couple of years and where we're
going, we kind of divided the Friendship Bench
into three main components.
The first part was the research and development,
which was really the formative phase of Friendship
Bench, where in the absence of resources we
had to come up with an intervention which
was simple, cheap, but was addressing a huge
problem, and apart from that we needed an
intervention that would address a diverse
population.
And we managed to kind of achieve that, looking
at Zimbabwe as an isolated country, but really
when you're thinking of an intervention that
is likely to be scaled up it has to be replicated,
and so we were thinking of the next stage,
which is replication.
Can the Friendship Bench in its current state
be replicated in places outside of Zimbabwe?
And if it can be replicated then it can really
go to scale, and this is what we would see.
And so we started the process of replication
in Malawi, in New York City, in Zanzibar and
Botswana, and the model seemed to be quite
intact in terms of its replicability in different
settings, different cultural settings, and
so we're kind of confident that this really
can go to scale.
Now, one of the things that we observed while
we were running the Friendship Bench is that
not all young people were comfortable sitting
on a bench with grandmothers, and also we
realized that some people preferred to communicate
a lot more using, you know, digital technology,
mobile phones with the grandmothers, and we
teamed up a couple of years back with folks
from Philips, with Robin and others, and we
came up with an intervention which supports
Friendship Bench called Inuka.
Inuka is a Swahili word which means "Arise,"
and the rationale behind it is, if Friendship
Bench can be scaled up, Inuka as a digital
platform could enhance that scaling-up process,
and so in essence Inuka becomes a digital
platform which is in addition to the existing
Friendship Bench which has been running since
2006, and so it's an app which can be downloaded
and it's really based on the same principles
of the Friendship Bench.
And the idea is with this approach of having
these grandmothers, for instance, in Zimbabwe
who deliver an intervention on a park bench
in the community, and at the moment we are
operating in more than 70 communities in the
country, and obviously we also have communities
outside of Zimbabwe.
With that kind of intervention, which is then
supported using digital platforms, we are
able to reach out more people.
We are able to provide a lot more support
to the grandmothers via these digital platforms,
and this has been reflected in the work that
we've been doing in New York City, for instance,
in Zanzibar, where there's a need for that
digital platform.
At the moment, some of that digital communication
is facilitated through WhatsApp, you know,
through Skype, and so Inuka comes in as something
that could effectively take over that role
and enable strengthened communication to really
enhance our reach and impact.
I'd just like to share some of the Sustainable
Development Goals which specifically focus
on mental health, just to sort of highlight
why an intervention like Friendship Bench
is important.
So if you look at target 3.4, 3.5, and 3.8,
they all kind of really touch on mental health,
and there's this growing need when you look
at the global burden of mental, neurological
and substance use disorders, there's a real
need to scale up interventions that truly
reduce that treatment gap for mental, neurological
and substance use disorders.
We cannot train enough psychiatrists or clinical
psychologists, that is common knowledge, however
through task-shifting we can make a huge difference
in a very short space of time, but the challenge
is finding task-shifting interventions which
are really solidly rooted in evidence, which
are based in empirical observation.
I believe that the Friendship Bench is one
such intervention which can contribute significantly
to reducing that treatment gap.
I'll get on to why I think grandmothers are
also a critical role, or the elderly population
in the world, a little bit later.
Just to give you a few examples from two very
different locations, that is Zimbabwe and
New York City, here we have the oldest graduate
from Zimbabwe, she's 84 years old, but on
the right...
I don't know what happened to my animation,
it's not showing.
The lady on the right is from New York City,
her name is Skip, and the common thing that
really unites or brings these people together
are the lived experiences which they bring
on the bench, and this is something that we've
found to be really powerful, where lived experiences
or the stories that people bring to the bench
are rooted in CBT principles, and empirical
observation, because the whole thing is about
measurement.
If we can't measure what we're doing then
we really don't know if it's working, and
so by bringing in and injecting something
like CBT and the use of validated screening
tools, while you give stories, you're able
to tell how a person is improving, what kind
of progress that person is making.
And so what has essentially happened over
the years is something that started off as
a strongly CBT-based intervention has really
become more of CBT through storytelling, CBT
through the use of evidence-based tools which
are validated within a local context.
This is a picture that I often like to use
to illustrate the power of using ordinary
people in communities.
This is a picture of the very first grandmother
who worked on the Friendship Bench in Zimbabwe.
Her name is Grandmother Jack, and Grandmother
Jack was the first person who started doing
this work, and she gave hope to all of us
because she was really dedicated in what she
did, and she would persistently be there every
morning seeing her clients.
It was something that we expected of her to
do, you know, and one morning when she didn't
come to work, we kind of all knew what had
happened to Grandmother Jack.
But what really illustrates the Grandmother
Jack story is that if you think of the world's
elderly, the population of elderly people
in the world today, you know, if you look
at 65 and above, you know... it's estimated
by the World Health Organization and the UN
that there are over 600 million people aged
65 and above, and then within another 15 years
it's going to be over a billion people aged
over 65, and the older one gets, the richer
the lived experience is.
And what we are learning from the Friendship
Bench is if we can take those lived experiences
and inject a fair dose of evidence-based talk
therapy, they really can reach out to thousands
of people addressing the global burden of
depression for instance, and contribute significantly
to averting suicides.
This is what we have seen in Zimbabwe, we've
seen this in Malawi, we are seeing this in
New York City, we are seeing it in Zanzibar,
and more recently in Botswana, so this is
what I really wanted to share with you about
the work that we're doing in Zimbabwe, and
why I think that this kind of work can make
a difference, and this kind of work is really
what's going to contribute significantly towards
narrowing or reducing the treatment gap for
mental, neurological, and substance use disorder
on a global scale.
If anyone is interested in learning a little
bit more about the Friendship Bench, you can
look up my TED Talk which goes into more detail
of how the Friendship Bench actually works,
but I can also take some questions. Thank you.
Let's have a seat.
Sure.
So, thank you for your presentation.
Questions from the audience can come through
the Bizzabo app, or of course on the website,
the mobile website is london.eaglobal.org/polls.
So, let's talk about how it works, because
that was kind of what I was wondering about
most as I was listening to you.
I mean, it seems like you...
I've also pulled up the website and there's
a tremendous number of publications, and also
media reports, but what does one kind of experience?
We're almost on a bench type of scenario-
Yeah.
I'm a little hesitant to volunteer myself
as a subject, but if appropriate I would be
willing to do that, but... or you could just
kind of describe like, what is the nature
of the experience as people actually have
it?
Sure.
So, the Friendship Bench model consists of
I guess two critical components.
The first component is the preparation of
the grandmothers, so in essence what we do
is we first train trainers.
The trainers then train the grandmothers,
and the trainers that train the grandmothers
end up supervising the grandmothers once the
grandmothers are in the field.
And the actual CBT component consists of three
steps, very simple steps, which are rooted
in behavior activation, activity scheduling,
and in problem-solving therapy.
The first component is called "Opening the
mind," in Shona it's called "Kuvhura pfungwa."
The second component is uplifting, and the
third component is kusimbisa, and how it essentially
works is people are referred to the bench
from everywhere, from schools, from the police
station, from the clinics, from homes, and
some people just self-refer.
Some are referred through radio talk stations,
and when they come to the bench the first
thing that happens is they are screened.
They are screened using a locally-validated
screening tool.
I think here in the UK with IAPT you use PHQ-9.
We also use the PHQ-9, but we also have a
very specific locally-validated tool called
the SSQ, which is broader.
And screening tools are critical, because
if you don't use screening tools in this kind
of work, it's difficult to have structure.
So the screening tools inform the grandmothers
whether they are dealing with a severe case,
a moderate case, a case that needs to be referred
to the next level, and so once they establish
that this is a case, they then provide the
talk therapy, which is really consisting of
those three steps, and normally it's over
a series of about four sessions.
So it was opening the mind, uplifting-
And strengthening.
Strengthening.
Those are the three critical components.
So, can you describe each of those in a little
bit more detail?
Opening the mind essentially is the storytelling
part, where the grandmother listens to the
stories.
So you know, classically people who come to
the bench have a whole lot of problems.
A whole lot of issues, everything is just
kind of going wrong in their lives, and people
will often present with a number of problems,
not just one problem.
A person may present with being HIV positive,
unemployed, having no place to stay, having
children who are not at school, you know,
just a whole lot of problems, and what we've
also realized is when people present with
these kind of problems, they get into an almost
kind of learned helplessness, where they can't
really figure out which problem to start working
on.
An interesting thing is, we thought this phenomenon
was specific to Zimbabwe, but we see exactly
the same thing in New York City when we look
at the cases that they are dealing with in
the Bronx and in Harlem.
It's pretty much the same, people with all
these problems and just not knowing where
to start, and sitting on the bench and having
somebody say to you, "Tell me your story,"
is just such an amazing sort of way of opening
up, and realizing that there's actually someone
who can listen to me, someone who can help
me.
So that's really the first stage, you know,
opening up the mind through opening up and
telling those stories, as painful as they
are.
And one of the other things which we also
encourage on the Friendship Bench, which is
really not in-keeping with your usual psychotherapy
or CBT therapy is the therapist becomes almost
involved, you know?
And this is something that I was never trained
to do as a psychiatrist, you know?
You always keep your distance, but we've learned
from the grandmothers that it's critically
important to show your weaknesses too as a
human being by sharing your own lived experience,
but within a very structured way, and by doing
that you really establish strong rapport with
the client.
So anyway, so the client talks about their
story, and while they're doing that the grandmother
simply lists the problems that are highlighted.
That's all she does, and she listens with
a lot of empathy, with a lot of appropriate
physical gesture where called for, and after
all of that has happened the grandmother simply
summarizes what she hears.
And that particular component is also very
powerful, because when somebody tells you
their story and you are able to accurately
summarize what they've told you, that's a
sign that you've been listening, and that's
a sign for that person who's telling their
story that, "I've got someone who's on my
side."
And really, that's why we call it "Opening
up the mind," because most of these people
have never really talked about their problems
to anyone in such a setting, and so when that
happens the grandmother then summarizes, and
after summarizing asks the client to select
a problem to work on, so like your traditional
PST, you know, and then it goes on from there,
where they brainstorm to come up with a solution,
and essentially come up with a very specific,
measurable, achievable, realistic and timely
solution that they focus on.
Very, very practical, but with a very strong
dose of emotions and human contact.
And is that now the uplifting phase?
So the sort of end of the opening the mind
is the kind of recounting back to-
Yeah.
It strikes me that this is also sort of an
instruction manual for how to be a good friend.
Yeah.
To a very significant extent-
Well, that's why it's called "Friendship Bench."
So, you've kind of recounted now to your client,
"Here's what I heard from you," and then uplifting
is this kind of brainstorming-
Yeah.
Choosing a particular thing to sort of focus
on first, brainstorming solutions to that,
and then how far does that go and what is
the strengthening phase?
So, the strengthening phase is essentially
the part where you then start to clearly identify
a single problem and break it down in terms
of what happens, but a critical component
of the strengthening phase is something that
we call "The holy cow moment."
And we call it "The holy cow moment" because
it's one of those stages in therapy where
the therapist is interacting with the client
and you've listed all these problems, and
I used to struggle with that, you know?
So you list all these problems, you know,
"I'm suffering from HIV, my neighbor is not
talking to me, my husband is abusive, I have
a pregnant teenage daughter," and with my
mind as a medical doctor and psychiatrist,
when I hear HIV, the first thing I think of,
"We've got to put this person on medication.
We have to make sure that the CD4 count and
the viral load is all in place."
And then when you actually discuss with the
client, and the client identifies a problem
to focus on which just doesn't fit with you
and your thinking as a psychiatrist, that's
what we call the "The holy moment," and we
struggled a lot with the holy moments with
the grandmothers as well, because initially
they would prioritize certain things, but
we also realized that handling that "holy
cow moment" where a client selects something
that seems really ridiculous to focus on,
is critical.
And what we essentially do is we encourage
the grandmothers to deal with the "holy cow
moment" as it comes, so if a client chooses
to focus for instance on something which seems
trivial, focus on it, because what we've learned
over the years is by focusing on that which
seems trivial to us, we actually are opening
up avenues to treat all the other problems
that seem massive.
So that becomes the strengthening component,
where the client realizes that, "Regardless
of the problem that I've selected to focus
on, this person is still prepared to work
with me."
And once that is done, the third stage which
is the strengthening, kusimbisa, is in essence
the homework.
Because the beauty of what we do on the Friendship
Bench, which is different from your traditional
therapy, is your first session, the focus
is to make sure that you walk away from there
with a solution.
We don't believe in telling people to come
back for three, four sessions before a problem
is solved.
You know, people in Africa are very mobile,
they're constantly moving, and if a person
spends an hour and a half with you and you
can't solve your problem, they're pretty much
not gonna come back.
So we really do emphasize on making sure that
they go home with something tangible that
they can work on, that's the strengthening,
and then part of the strengthening involves
the grandmother calling up on the client,
either by sending an SMS, or sending a WhatsApp
message, and just to touch base, to see how
the client is doing, and this strengthening
carries on because they will in essence meet
sometimes outside, when they are in the marketplace
or in the community, and she can do a five
minute strengthening.
"So how is it going?
How are things?"
You know, that kind of stuff, and so that
just kind of goes on, carries on.
So a lot of questions actually from the audience,
kind of focused into two categories.
One is on the grandmothers and sort of how
they're selected, where they come from, their
role, and then the other kind of on your organization,
and how it's funded and how it can grow.
So let's start with the grandmothers, I guess
how was it that you started with grandmothers
in particular, and have they been kind of...
is it validated that grandmothers in particular
are the right people to be doing this, versus
any other group of people?
So, for Zimbabwe certainly grandmothers are
the best.
We have consistently found that grandmothers
are reliable.
You know, they are rooted in their communities
and they have this wealth of wisdom which
is very culturally appropriate.
You know, they are very good with using appropriate
proverbs, you know, to actually get through
a problem, and they're just... they give very
good hugs as well, you know?
So for Zimbabwe certainly, we certainly love
the idea of grandmothers, but we are also
working with young people.
We are working with young people as well.
If you go to New York City, they don't have
that many grandmothers.
They do have sort of...
New York City I guess has a very diverse group
of people working on the bench, from about
24 years old all the way up to like 56, you
know, so that's what works for New York City.
I'm strongly in favor of working with grandmothers
for the simple fact that we find them to be
more reliable, you know, but I think this
model can be used for anyone.
Anyone can deliver this model, and the grandmothers
that we're working with, as I indicated in
my presentation earlier on, they... in essence
I was given grandmothers, you know, because
I guess the city health department thought
that grandmothers are not so important, so
try and come up with a solution with grandmothers,
and all the other younger... the nurses, the
mental health professionals were busy doing
other things, so it's not that I chose them.
That's what I had to work with, which was
a blessing in disguise actually, you know?
And then coming up to the issue of... what
was the second question about the...
Your organization, and there's a number of
questions, but who funds it?
Are you looking to expand, are you looking
to start something in the UK?
What could you do with more funding?
All of that has been asked.
So, I mean obviously we would love a lot of
funding.
So, we run a trust called the Friendship Bench
Trust.
So initially when we started Friendship Bench,
as I indicated in my presentation, was really
my thesis, my fieldwork for my Master's in
Public Health.
That's really how it started, and it just
carried on since 2006.
It has grown, and we are now a Trust, a registered
Trust in Zimbabwe.
We are hoping at some stage to be registered
here in the UK, because I'm kind of affiliated
to the London School of Hygiene and Tropical
Medicine, so that's the idea.
Most of our work has been funded by research
agencies like the Wellcome Trust, NIH, MRC.
This is why our work is heavily research-based,
but we also do realize that as we think of
scaling up the Friendship Bench, we really
need to move to a different kind of funder,
because most of these research organizations
or funders do not fund scaling up of programs,
and I think the Friendship Bench has acquired
quite a lot of evidence to justify taking
that next step, which is scaling up.
Yeah.
So, we are unfortunately just about out of
time.
Do you have office hours his afternoon?
I don't know.
All right, well maybe we'll find something
to add there, and you can check the Bizzabo
app for that.
I guess one last question would be, for those
that are interested in kind of going a little
bit deeper into the subject matter, are there...
you mentioned kind of trainers to train the
grandmothers as the first step, but is there
any sort of self-training materials that people
could access somewhere online?
So, we do have... if you go to the Friendship
Bench website, we do have a manual that is
available that we use.
We have a facilitators' manual, and we have
a training manual for the delivering agents,
but we also have the Inuka platform, which
offers the training of guides as I indicated
earlier on.
You've got Friendship Bench, which was the
original program which started in Zimbabwe,
and now we have a digital component which
is really based on what we've done in Zimbabwe,
and for Inuka we actually hopefully wanted
the gains to run smoothly.
At the moment we are testing Inuka.
Inuka has been tested, piloted in Zimbabwe,
in Kenya, and we've done some work in India,
so at the moment we are actually running a
pilot in Kenya, but we would love to have
guides on Inuka once it starts to run.
Yeah.
All right, well again, that is unfortunately
all the time we have, but how about a big
round of applause for Professor Dixon Chibanda?
Thank you.
