An estimated 150 million Americans live in areas that lack mental health professionals. In the coming years, the country faces a predicted shortage of up to 30,000 psychiatrists, psychologists, social workers, and other mental health caregivers. More than 60 percent of psychiatrists are 55 or older and approaching retirement. And, right now, there are too few residency spots to train clinicians. In order to meet the scale and intensity of the need, we may need to reimagine mental health care in fundamental ways.
Two decades ago, a talented young psychiatrist in Zimbabwe named Dixon Chibanda was thinking about strikingly similar challenges in a very different context. His country had an even more extreme shortage of mental health professionals: He was one of only 15 psychiatrists in a country of 16 million people.
Chibanda lost a patient — a young woman with a promising career and life ahead of her — to suicide after she was unable to access mental health care in her village and couldn’t afford the $15 bus fare to travel 160 miles to see him. After the tragedy, Chibanda decided to devote his career to the vexing question of how to help people who most need mental health care but who face financial, geographic, or cultural barriers to access.
After exploring several ideas for recruiting and training mental health practitioners, Chibanda found that there was, in fact, already a large cohort of experienced, empathetic, respected caregivers who were ready and willing: grandmothers.
“The most important resource that is left in most communities are grandmothers, because they are custodians of the local culture and wisdom,” Chibanda told a global symposium on reimagining community in 2019.
Chibanda worked with the Ministry of Health and Child Care and the University of Zimbabwe to develop a pilot program to train older women in a mode of evidence-based talk therapy known as “problem-solving therapy.” The aim was to reinforce the women’s capacity to listen, to make people feel heard and seen, to give patients a feeling of belonging, and to help them gain the confidence to find their own solutions.
In consultation with an inaugural group of 14 grandmothers in Harare, Chibanda decided that, rather than seeing people under the fluorescent lights of crowded clinics and hospitals, the grandmothers could provide their services in a simple, unpretentious, and accessible location: a park bench.
From the beginning, the grandmothers shaped the free program. When Chibanda initially proposed calling it the “Mental Health Bench,” the women balked. They suggested calling it the Friendship Bench as a way of eliminating shame and stigma.
They also advised the use of local idioms and the avoidance of overly clinical language. For example, rather than talking about depression or anxiety, the grandmothers often use the gentler Shona word kufungisisa, which translates as “thinking too much.”
One program participant, Susan Chali, first went to the Friendship Bench when her marriage was in crisis and she was struggling to feed her children and pay their school fees. “In the beginning, I thought I was no longer human because of the troubles that I had,” Susan told me when we met in July 2020. With few resources and little formal education, she didn’t feel equipped to reach out to any social service providers.
When Susan first met her “grandmother,” Sabinah Dovi, their sessions on the bench focused only on ensuring that Susan felt love and respect. Over time, their conversations shifted to practical problem-solving, including how Susan could better communicate with her husband and how she could start earning some income for herself.
“The way Sabinah talked to me,” Susan told me, “she removed all the pain I had in my heart. I started out crying, but in the end I was happy. I got the feeling that I was accepted in the community.”
This empowering sense of acceptance and belonging underlies many of the Friendship Bench interactions — and it is reciprocal. Grandmothers I spoke with reported gaining strength and sustenance from feeling part of a community that extends beyond the bench. “I learned that I am important to other people,” Sabinah said. “People keep coming to me — it makes me see that I’m doing a good job in the community.”
Ruth Verhey, a researcher associated with the program, has studied the effect of the Friendship Bench on the grandmothers and found that their participation correlates with a lower incidence of a range of common mental health disorders, such as anxiety and depression.
Part of the power is camaraderie. The program facilitates social connectedness among the grandmothers. Yet it’s also about purpose. Grandmother Sabinah, who helped Susan through her challenges, told me, “When I’m working, I put all of my heart and all of my effort and energy into doing it. . . . It creates an identity for me. And wherever I go, I carry that identity with me.”
The grandmothers feel like they’re part of a movement, and this is an antidote to isolation. In America and elsewhere, many psychiatric care professionals are overworked and overburdened. Inherent to the challenge of addressing the mental health care crisis is ensuring that workers are supported, recognized, and made to feel that they’re doing essential work.
There are now close to 100 peer-reviewed studies on different aspects of the Friendship Bench, including its effectiveness. Research on the program, published in the Journal of the American Medical Association in 2016, found significant improvement in participants with depression who received therapy from a trained grandmother. At six months, participants who interacted with these lay health workers were — according to a range of indicators, including fear, anger, and sleep patterns — better off than those who received therapy from a community mental health nurse or psychologist.
Last year, the program reached just over 60,000 people in Zimbabwe. Similar projects inspired by the grandmothers have been launched in locations from Kenya to Vietnam. The program is a model for pilot efforts around New York City — including in the Bronx, Harlem, and Brooklyn — where volunteers staff orange pop-up benches at street fairs and other events.
Last fall, the model was temporarily exported to the FIFA World Cup in Qatar to cast a spotlight on mental health. In partnership with the World Health Organization, 32 Friendship Benches were set up at various spots in Qatar, each representing the competing teams.
The power of the program isn’t just in the easily replicable setup or even in the skill of the providers. It’s in how it empowers everyday people to take responsibility for the psychological well-being of their community.
As policymakers and clinicians propose solutions to address the mental health crisis in the United States, they’d do well to consider the Friendship Bench as a model. While such efforts as Massachusetts’ new 24-hour help hotline (833-773-2445) and community clinics are steps in the right direction, the Friendship Bench simplifies access. By over-medicalizing such resources, there’s a risk of alienating struggling people, including those from historically marginalized groups who have been poorly served by the health care system.
“If you’re going into a community and use the local language and promote the program using your local language, it’s more acceptable and people understand it better and are able to relate to it,” Charmaine Chitiyo, a grandmother who serves as a trainer, told me. “We feel it really helps to destigmatize.”
While the idea of belonging is ubiquitous these days — from product marketing to corporate HR-speak — the Friendship Bench demonstrates what the word can really mean.
Once a Friendship Bench participant has been through six sessions, they can be referred to a Circle Kubatana Tose group, a term that means “holding hands together in a circle.” In these meetings, participants pass a stone around, taking turns speaking about the challenges they’re facing. The group then turns its attention to tackling a community issue — for example, helping people living with HIV get the right medication or helping single mothers get funds to pay their children’s school fees.
The idea is to take the work from therapy to community. Through the cultivation of a rich connection with other people and a sense of shared purpose, participants can find an experience of belonging — in itself a powerful bulwark against psychological distress.
The Friendship Bench is not a high-tech medical intervention. It’s not a disruptive innovation to health care markets. Rather, its potential is in its simplicity. It’s an effective way to put into practice what humanity has known since time immemorial: that quality connection is the most important determinant of good mental health.
Kim Samuel is author of “On Belonging: Finding Connection in an Age of Isolation.” She is the founder of the Samuel Centre for Social Connectedness in Montreal and is a visiting research fellow at Green Templeton College, Oxford University. Follow her on Twitter @kim_belonging.