Are Grandmothers the Key to Solving the Global Mental Health Crisis?

The facts and figures around traditional mental health in Zimbabwe are stark. In the nation of 14 million people, there are only 19 psychiatrists, and two psychiatric hospitals. Zimbabweans who pursue the path of becoming accredited mental health professionals also face immense financial incentives to leave—the classic “brain drain” problem. It is also a country whose people bear the scars and traumas of the past, from the brutal and isolated period of Ian Smith’s Rhodesia (and generations of war and colonization before that) to the mismanagement, violence, and repression of Mugabe’s 37-year rule. An estimated 70% of Zimbabweans suffer from untreated mental health issues such as anxiety, depression, and PTSD. These pathologized labels, however, can be alienating to many people.

Part of Friendship Bench’s success has been to replace imported Western terms with culturally appropriate language and concepts. For the most common conditions—depression and anxiety—the term that most people feel fits their symptoms is kufungisisa, or “thinking too much.” The Friendship Bench method de-stigmatizes mental health—whether it’s trauma, intimate partner violence, or living with HIV, the Friendship Bench provides a welcome opportunity to open up to someone who has seen it all and will not judge.

After Dr. Dixon Chibanda lost a patient to suicide in part because she lacked the $15 bus fare to come to Harare, Dixon was deeply affected and came to the conviction that the existing model of care, in his words, “just wasn’t going to work.” But in a context where there were fewer than one psychiatrist or psychologist per million people, what would? “It dawned on me,” says Chibanda, that “one of the most reliable resources we have in Africa… are grandmothers.” Trying to create a system so that patients can be better served in their own communities has been Dixon’s way of healing his own trauma, and in the process, he has discovered a way for entire societies to heal theirs.

The model’s success in Zimbabwe has already brought it to new contexts. Zanzibar, Malawi, Vietnam, and Kenya have begun pilot programs of their own. With a combination of face to face and online training, Friendship Bench can train new community health workers anywhere. In addition to CBT, that training includes psychoeducation, counseling skills, mental health literacy, screening methods, problem-solving therapy, and instruction on how to conduct sessions, use diagnostic tools, make referrals, and also to practice self-care. Once trained, grandmothers are receive ongoing supervision and opportunities for deeper training on specific health topics and complex cases. Sessions are randomly observed and assessed (with patients’ permission) to ensure quality and accountability.

The data makes it clear why other countries are eager to replicate it. Of 200,000 people who went through treatment from 2016-2022, 78% showed improvement in their screening scores. Friendship Bench has led to over 100 scientific, peer-reviewed publications that support these findings. Not only that, but the research suggests that being treated by grandmothers is a more lasting and effective treatment for depression than most clinical care. It also provides an important role, and income, for elders in their community. Interviews with the grandmothers show an increased sense of belonging, connection, and feeling appreciated by their community.

Following sessions with grandmothers, individuals are invited to join over 400 peer-led support groups, called Circle Kubana Tose or “Holding Hands Together”, that combine community group therapy with opportunities to design income-generating projects. By far the most important outcome of Friendship Bench, however, is how it has delivered care at scale in a place where before it was impossible—a discovery that has the potential to revolutionize mental health worldwide.