Friendship Bench Global
An evidence based psychological therapy delivered by trained community grandmothers (lay health workers) from wooden park benches.
I am the founder and Executive Director of the Friendship Bench program, an evidence based psychological therapy for depression delivered by over 700 trained community grandmothers on wooden park benches in over 100 communities in Zimbabwe and beyond. As a psychiatrist with over 10 years experience in both clinical and research work, I provide oversight and leadership to the Friendship Bench team. I articulate the vision, mission and values of Friendship bench to the wider global community through regular peer reviewed publications, conference presentations and speaking events. My past experience is rooted in research aimed at developing innovations that narrow the treatment gap and increase access to treatment for depression, a leading cause of disability globally.
Friendship Bench Global
An evidence based psychological therapy delivered by trained community grandmothers (lay health workers) from wooden park benches.
1. Depression affects over 300 million people globally and suicide is a leading cause of death among young people. Our research proves that community lay workers can be trained to deliver effective talk based therapy as treatment for depression and suicide prevention. Our project, based on an RCT published in JAMA, trains community grandmothers who are rooted in their communities to treat depression and prevent suicide.
2. By identifying suitable organisations located outside of Zimbabwe and training trainers, who in turn train community grandmothers, we propose to scale our work over the next 5 years, to reach 5 Million people currently suffering from depression who do not have access to any form of therapy.
3. Our project empowers individuals and communities to problem solve around mental health and economic challenges and creates a collective sense of belonging within communities.
Depression affects over 300 million people globally and loneliness together with suicide are now global epidemics which are closely linked to depression. According to the World Health Organization, 90% of people requiring evidence based mental health care have no access to services and support. This results in tremendously negative mental, physical and economic outcomes. In Zimbabwe and most low and middle income countries, there is on average, 1 psychiatrist/psychologist for every 1.5 million people. Over the past decade, we have developed a delivery program that trains non-professionals, such as community grandmothers, to deliver a series of effective talk based therapy interventions, coupled with a community support group, which narrows this treatment gap. In a country like Zimbabwe where 1 in 4 adults are affected by depression with 12 psychiatrists for the population of 14 million, training non-professionals to reduce the treatment gap is vital.
To expand our work beyond Zimbabwe, we will identify suitable partner organizations, using our in-house suitability checklist, and run a theory of change workshop (ToC) to build consensus and define our path to integration. We train trainers from these organization in groups of 20-30 in basic cognitive behavior therapy (CBT). Trained trainers work in pairs training up to 30 grandmothers over a one month period. We sensitize communities (hospitals, clinics, police stations schools etc) via social media and radio to refer to the Friendship Bench. Trained grandmothers are allocated a wooden Friendship Bench in their community from where they screen referred clients based on locally validated tools. Clients scoring 8 and above on the screening tool, receive 4-6 structured sessions of CBT over a 4 week period from a grandmother on a bench (or virtually during covid). Our work emphasizes empathy and compassion, rooted in brainstorming for solutions. After 4-6 sessions clients who improve are invited to join a community support group (physically or virtually via WhatsApp during Covid) while those needing further sessions continue or are referred based on an algorithm. Support group members collectively use techniques learnt from the grandmothers to continue problem solving collectively.
We serve poor communities with little to no access to mental health care primarily in Zimbabwe but have introduced similar pilots in Malawi, Tanzania, and Kenya. Our clients are mostly women (85%) aged between 16-80 who have experienced psychological challenges which include depression, loneliness, suicidal behaviour and intimate partner violence, and other forms of trauma. Each client visiting the Bench is asked a set of socio-demographic questions which inform our team of their needs. A screening tool is then administered to establish the nature of the psychological challenge (diagnosis). The tool also enables our grandmother to triage clients according to severity of symptoms as part of an algorithm. After receiving 4-6 sessions on the bench they are actively invited to join a support group in their community which provides an opportunity for collective problem solving at community level and income generation. The support groups provide an opportunity to understand the challenges that communities face and enable members to collectively brainstorm around solutions which they implement in communities. At each and every level of our model our team provides technical support in the form of supervision, M&E, and data collection/analysis which gives rich insights on the users and their needs
Elevating opportunities for all people, especially those who are traditionally left behind
Women in Zimbabwe and beyond are often marginalised. Friendship Bench creates safe spaces and a sense of belonging for women in communities by empowering hundreds of community grandmothers to provide basic problem solving therapy to thousands of women affected by common mental disorders such as anxiety and depression which are often associated with poverty, domestic violence and physical ill health. Through the 4-6 sessions on the bench people are empowered to take ownership of their problems and collectively through the community support groups (CKT) they transform and empower each other and their communities.
In 2006 I was the only psychiatrist working in public health in Zimbabwe, It was against this background while working in a psychiatric hospital that a young patient of mine took her own life by suicide while at home. Her name was Erica. When Erica’s mother broke the news to me over the phone, I couldn’t help asking why she had not brought Erica to the hospital for her scheduled review. Her response was brief, “We didn’t have the $10 bus fare to come to the hospital”. Her words left me stunned and after weeks of soul searching I realised that I had to take mental health care to communities for people like Eric to have access to care within walking distance. With no resources at hand except a group of 14 volunteer grandmothers, through an iterative process I came up with the idea of therapy on a bench in communities across the country, delivered by trained grandmothers. For the first 4 years with only 14 grandmothers I supported the initiative out of pocket using my salary. Today I have over 700 grandmothers who have together reached out to over 70 000 people in over 100 communities.
At medical school I lost a close friend to suicide. A person with a bubbly predisposition who was always willing to help others. His death left me perplexed and deeply disturbed. It was this tragic and seemingly out of context suicide that got me thinking about mental health. Although I had not at the time wanted to study psychiatry having preferred to specialise instead in paediatrics, the suicide brought new insights into my own personal life and understanding of human relationships and emotional suffering which ultimately shifted my focus to psychiatry. My work has remained important to me not only due to personal reasons which include Erica’s story described above but also through the realisation that depression is a leading cause of disability globally and every 40 seconds someone takes their own life by suicide. The loss of Erica, in particular, during my early years as a psychiatrist would further shift my focus and help me to strive to make sure that all those in need of care have access to it within walking distance. This has become the mission of my work, “to have a friendship bench within walking distance for all”
In the past 10 years I have focused on living and telling the story of the Friendship Bench through different platforms based largely on my personal journey with the grandmothers. Rooted in empathy, connection and research, the Friendship Bench has made it possible for over 50 000 people to access evidence based therapy in Zimbabwe in over 100 communities under my leadership .I have facilitated the introduction of Friendship Bench in several African countries as pilot projects including in the USA in the Bronx NYC. I have also made it possible for Friendship Bench to be recognised as a programme that is anchored in rigorous research with over 50 peer reviewed scientific publications including a cluster randomised trial published in JAMA which showed the effectiveness of using grandmothers to treat common mental disorders such as depression and anxiety.
Prior to the COVID outbreak Friendship Bench services were exclusively delivered from wooden park benches. As the lockdown and social isolation began to affect communities with a rise in mental health issues, loneliness and reports of intimate partner violence, I gathered my team and informed them that we would have to rapidly transform our training, supervision and service delivery to digital mode and any other possible virtual platform that would make access to grandma therapies easy for communities. We gave ourselves a deadline of 2 weeks to explore what was possible. After our survey revealed that 80% of the population relied on WhatsApp for communication we decided to use this platform as our initial mode of delivery for the virtual Friendship Bench. Over a 4 week period with several consultations with tech based organizations we developed a WhatsApp based training, chat, audio, and video delivered package. We piloted the approach with 15 grandmothers looking at feasibility, and fidelity of the approach. This was followed by the introduction of the approach to more grandmothers. We have subsequently included a voice call platform and this has now become an alternative form for the delivery of our new virtual friendship bench.
In 2017 I wrote an op-ed published in the Guardian (UK) where I described Zimbabwe as a country characterized by 4 generations of trauma needing genuine psychological healing. I particularly highlighted the genocide of over 20 thousand ethnic Ndebele speaking people under the current government. In response, the government threatened to shut down all Friendship Bench activities. With the team in panic mode, I reassured them as I consulted legal experts, my trusted grandmothers and stakeholders from civil society groups. After consultations I decided with my team to be more conspicuous in the face of adversity through social media. In addition I engaged a prominent documentary film maker to run a story of Friendship Bench which was launched in Harare and widely discussed on social media. I attended a series of local and international speaking events where I articulated the achievements of Friendship Bench. Together with my team we made Friendship Bench more conspicuous and relevant for ordinary struggling people who in turn gave us overwhelming support. Through sustained advocacy from several fronts particularly community groups the Friendship Bench survived and was subsequently integrated in the national strategic plan for mental health.
Not part of a larger organisation
We are innovative because we have created a new narrative around talk therapy. Once believed to be in the hands of professionals such as psychiatrists and psychologists we have taken therapy to wooden park benches in poor communities with local grandmothers trained to be the therapists. We leverage mobile phone technology which is growing rapidly in Africa to provide supervision and continued care during the COVID crisis and beyond. The Friendship Bench is simple, cheap and evidence based with over 50 peer reviewed scientific publications. Our randomised clinical trial shows that 6 months after receiving therapy from a trained community grandmother participants were still free from depression and no-longer showed suicidal thoughts. Rooted in our values of empathy, connectedness and research Friendship Bench continues to innovate by regularly immersing our team in the communities we work to leverage on the transformational stories that create a sense of belonging and purpose for the disadvantaged and marginalised.
The desired impact of Friendship Bench in the next 5 years is to improve the quality of life of 5 million people through the creation of safe spaces and sense of belonging in communities by enhancing collective mental well-being.
Resources/activities: Based on our rigorously evaluated model published in JAMA (JAMA 2016; 316,24), we have developed a train the trainer model, and built capacity of our team to bring Friendship Bench to new settings. We identify suitable trainers through our existing networks using our in-house suitability checklist. Trainers undergo a 1 month training based on local context defined through a theory of change facilitated by our team. Our team has extensive knowledge on how to conduct theory of change workshops (IJMHS 2016; 10, 1).
Each training trainers caters for up to 30 trainers. After training, trainers work in groups of 2 and go on to train between 20-30 grandmothers per training module which lasts up to 1 month (up to 4-6 trainings a year). Trained grandmothers are allocated a wooden park bench in their communities working in pairs of 2-3. In addition where they are not in possession of a mobile phone we make available a $30 mobile phone device and integrate our data collection tools which feeds into our monitoring and evaluation platform. We sensitize communities through social media/radio talk shows for clients to be referred to the bench using our in house communication protocols.
Grandmothers see up 4 clients a week on the bench in their community using our therapy algorithm which is both paper based and electronic through a smart phone . A supervisor is appointed for each area to provide support via mobile phone. After receiving 4-6 sessions on the bench clients are referred to a support group(CKT)in their community. Support groups are facilitated by a grandmother for the first 2-4 meetings afterwards they are community driven. Support groups provide a platform for collective community problem solving and enable communities to develop income generating initiatives which particularly seek to empower women.
We currently serve up to 50 000 people across Zimbabwe. These are people who have received up to 6 sessions of therapy on the Bench and have gone on to join a community support group where they meet regularly to problem solve around challenges faced at community level. As Friendship Bench we provide support to the grandmothers and communities to ensure smooth running of the program. The number of people being served in Malawi, Kenya and Tanzania (Zanzibar) are approximately 20 000 in total as these continue to function as pilot projects.
In one year we intend to reach out to 100 000 clients in Zimbabwe, while in Zanzibar, Malawi, Kenya we hope to reach 20 000 new clients.
In 5 years we aim to reach 5 million people in the 4 countries by rolling out our train the trainer model to increasing the number of grandmothers to 10 000 in the 4 countries. Out of the 5 million, based on our existing data we anticipate that 80% will receive at least 4-6 sessions on the bench and will see significant improvement in mental well-being (SSQ-score drop below 9 which is sustained for minimum 6 months). Out of the 5 million we anticipate that 60% will join a community support group either physically or via whatsApp and will stay in the group for at least 6 months.
In 5 years we aim to reach 5 million people who ‘s mental well-being will be improved leading to improved quality of life through sustained community participation in support groups. We will achieve this by training 10 000 grandmothers in 4 countries, with each grandmother reaching out to at least 4 people a week in their communities and facilitating the formation of over 2 000 support groups across the 4 countries. Friendship Bench will use its in-house expertise in implementing through training of trainers and providing regular technical support through scheduled visits and zoom meetings to all implementation partners.
In the next year our goal is to train 1000 grandmothers or their equivalent who reach out to 100 000 people in their communities and facilitate the formation of 250 support groups. Depending on the current COVID situation this will be achieved by either face to face contact or via digital platform. In the next 5 year period we will reach a total of 5 million people in 4 countries (Zimbabwe, Malawi, Zanzibar Kenya). We aim to train 2000 grandmothers in 2021, 2000 in 2022, 3000 in 2023 and 3000in 2024. Collectively they will reach out to 5 million people in their communities and facilitate the formation of between 2000- 5000 support groups.
Current barriers include 1) financial, 2) lockdown restrictions and 3) administration capacity.
Financial: Our annual running costs for Zimbabwe is 760 000 of which $478 000 has been secured for 2020. For technical supporting activities in Malawi, Tanzania (Zanzibar) and Kenya an additional $140 000 would be required for 2020 bringing our annual costs to $900 000 (see below). Currently secured funding for the next 3 years amount to $950 000. In particular the need to hire two new senior staff is one of our major financial barriers at present.
Covid-19: The COVID pandemic has resulted in a shift in our delivery mode with most of our work (in some areas affected by COVID) being delivered via WhatsApp, voice call and other forms of digital platforms. Working through a new platform has necessitated the training of our team, delivering agents, and data analysis team. While this is an ongoing issue feedback from both clients and grandmothers indicates that it is feasible and acceptable to deliver Friendship Bench virtually, however, this delivery mode needs further strengthening as our work expands.
Administration: Our core senior team (operations, programmes, finance and communications) have provided the leadership of the organisation, however, there is need for additional staff to cover activities linked to our global expansion. Our current core team is 25 with 4 senior team members. We anticipate onboarding an IT person to drive the digital platform and an expert with significant experience in implementation and scale science.
Financial: Currently we have part financial support in the form of grants for the next 3 years and we are applying for further grants to address the existing deficit. In addition we have developed a franchise model (described below) of Friendship Bench and we are in the process of assessing a number of interested organisations that would pay an annual franchise fee for technical support if they meet our requirements.
Covid: In response to covid we will continue to strengthen our digital platform particularly the use of WhatsApp, voice call and the Inuka digital platform. We will hire an IT/programmer who will work closely with our clinical team as we provide services online.
Admin: We intend to onboard two new senior staff members who will help drive our strategy to reach 5 million people
We partner with the research Support Centre (RSC) at the university of Zimbabwe which has administered some of our research grants and provided an academic environment to strengthen the research around our work. We partner with SoliderMed an NGO that is replicating Friendship Bench in Rural Zimbabwe with Friendship Bench providing technical support and capacity building. We are also partnering with Africaid an NGO that cares for over 60 000 young people living with HIV by integrating Friendship Bench in the work they do. In Malawi, Zanzibar and Kenya we are also partnering with existing NGOs and academic facilities where we build capacity to deliver Friendship Bench with the involvement of the local ministry of health.
On the digital front we have partnered with Inuka a digital based chat platform for mental-well being to explore how best we can integrate an appropriate back end to our WhatsApp based services.
The Friendship Bench seeks to create safe spaces & a sense of belonging in communities to enhance quality of life. Through a franchise and affiliate model, we will strive to increase access to mental health to millions of people living in low resource settings. The expansion strategy will be driven out of the Friendship Bench headquarters in Zimbabwe. The local, regional and international implementation strategy is supported by selecting, managing and supporting key partners. Our partners include nonprofit organizations and mission driven entities that serve vulnerable populations and have the capacity to both train substantial numbers of community members to deliver talk-based therapy and monitor the effectiveness of program implementation. Program delivery of the Friendship Bench activities is through a train-the-trainer model. In turn, partners provide data and participate in building the effectiveness of delivering talk based therapy through community members. Creating effective partnerships with implementing organizations is essential to creating a lasting impact in the communities we seek to reach and in supporting our scaling-up/expansion strategy.
The Friendship Bench activities depends on a diverse range of funding sources and streams of funding to sustain its operations, these include grants from INGOs, Foundations, Philanthropists. Financial Sustainability opportunities:
This will also initiate the development of a social enterprise model for the Friendship Bench.
$50,995.00 to train trainers and on board an operations director
received in 2020 $50,995.00
$11,010.77 for feasibility study into WhatsApp use
received in 2020 $11,010.77
$300,000.00 over 3 years to support growth
received 2020 $50,000.00
$73,300.00 for training of trainers/grandmothers & piloting
received 2020 $23,300.00
$134,000.00 to be released each year until 2023
received 2020 $134,000.00
$100,000.00 received from an anonymous donor through Goldman Sachs
received in 2020 $50,000.00
$ 7,576.34 from well wishers
$1,588.00 from overseas students coming to Friendship Bench for exchange programmes cost for accommodation in the Friendship Bench house.
Total awarded $ 478,470.11
Total received 2020. $328,470.11
In 2020 we seek to raise $760 000 for the Zimbabwe office/activities of which 478 000 has been secured. An additional $140 000 will be raised for technical support for Malawi, Kenya, Zanzibar for 2020 bringing the total to $900 000. We aim to raise about 80% of the $900 000 through grants, while 15% will be raised through our franchising system and 5% through earned income.We hope to raise the money by September 2020 for 2020 activities, while funds for 2021 are intended to be raised by March 2021.
Personnel cost for Zimbabwe, Malawi, Zanzibar and Kenya will be $230 000
This will go towards supporting the teams running Friendship bench mainly in Zimbabwe with additional support to 2 people in each of the 3 other countries.
Program costs for the 4 countries will be 600 000
Program costs are our largest expenditure which involves training, supervision, running workshops such as theory of change workshops physically or virtually via zoom, providing technical support analysis of data and publishing
Equipment 50 000
This includes laptops, desk tops, printers in all 4 countries and vehicle maintenance/repairs
Travel $ 20 000
Travel to existing and new sites in the region in the 4 countries
Salaries for the two senior team members. By on boarding these two new hires Friendship Bench will be in a stronger position to implement its scale up strategy and leverage digital technology. The Elevate Prize will also enable our team to provide more robust technical support to Malawi, Zanzibar and Kenya as we scale.
Our team would further benefit from further professional management and development services and connections with influencers mentioned above.
As the main voice of friendship bench I would benefit from a tailored marketing and campaign strategy which will ultimately increase our visibility fund raising abilities.
As we expand we will need a predictable funding and revenue model. Although we are currently working with a Franchise model we are still fine tuning this approach and would need support.
We are in need of hiring the right people with experience to take us to the next level particularly within the implementation and scale of the model.
Our monitoring and evaluation needs to be designed to manage big data as we increase the number of grandmothers and clients that we see.
We need an organisation that can provide input in putting together a systematic way of raising funds. Currently we are getting some support through the DRK foundation but our team would benefit from further support in this area.
We need organisations that can help identify the kind of people we would need to take our approach to the scale stage. An organisation that could provide both digital expertise and use of electronic packages for M&E would be helpful.