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

Galvanizing Tragedy Into Action

Dixon has expressed how the loss of his patient Erica in 2005 planted the seed for what became Friendship Bench, most notably in his 2018 Ted Talk. However, an earlier personal loss had put him on the path to becoming a psychiatrist.

In university, his friend Zeph, whom Dixon describes as “a bubbly, joyful presence,” took his own life. As Dixon grappled with the sudden and inexplicable absence of his friend, his focus shifted toward psychiatry.

The two losses changed how Dixon thought about his life’s work and his passion. Erica had known about her treatment options and wanted to come meet Dixon at the hospital to begin treatment, but she couldn’t afford the bus fare.

Eventually, these bitter seeds — loss, grief, shame, impostor syndrome, and guilt — began to unlock themselves from Dixon’s heart, and new possibilities emerged: he saw a gap in his local community that he was positioned to fill. He knew he needed to courageously take action on the new opportunity, even if he didn’t yet know what shape it would take.

Looking back, Dixon says he felt compelled to seek understanding, just as he had done as a child. Whenever turmoil upended his life, he sought a baseline of curiosity followed by forward motion. This had been instinctual in childhood, but it later became a conscious practice. Eventually, it became the philosophical underpinning of Friendship Bench: curiosity followed by tangible action.

“I learned how to just embrace life,” Dixon says, “and just be aware that, you know, things happen in life, but you have to keep moving.”

Kuvhura Pfungwa: Opening Up The Mind

The process of founding Friendship Bench unfolded over several years.

Although the losses of Zeph and then Erica were catalyzing events, Dixon’s initial response was shock and retreat, followed by grief, internalizing, processing, and uncovering.

This part couldn’t have been rushed, and he says it should not be rushed. Dixon credits Erica’s mother, Sekai, with the words that allowed him to begin bringing some of his pain to the surface: “It’s okay to cry, my child.”

As emotions threatened to overwhelm him, Dixon needed a change. He no longer wanted to go to work at the hospital because of painful memories. He considered studying orthopedic surgery, thinking that broken bones would be easier than the complicated, messy, harrowing landscape of human emotions. As much as this time was about running away from pain, he also began to run toward something new: a Master’s in Public Health.

“I just had this feeling that there must be an alternative way of doing things,” Dixon says. “Surely not everybody needs to be put on medication. And I started to do public health as a way of trying to understand more.”

Dixon says every psychiatrist’s worst nightmare is hearing a patient has died by suicide. After Erica’s death, the grandmothers who became Friendship Bench’s initial talent pool encouraged him to remove his psychiatrist hat and work differently, rooted in the local context. He realized that he himself was the establishment — the conventional wisdom that needed to be overcome. Getting close to his pain enabled him to challenge assumptions and gain clarity about what locals needed. Listening and being led by the community became cornerstones of his process.

A university supervisor encouraged Dixon, since the program offered funding support for startups solving community problems, and Dixon began working with local groups to understand the scope of the mental health crisis. Ironically, the town identified as an area of greatest need, Mbare, was the same town where his maternal grandmother, Ambuya Dhlamini, grew up.

Dixon self-funded most of the initial pilot, and he won a £2000 grant from the British government that provided FriendshipBench-branded t-shirts and umbrellas for the 14 grandmothers who would be his first staff, seven of whom are still alive and working today. Dixon was following what he calls “blind passion,” not thinking about scaling beyond Mbare. Yet as he began to tell his story and apply for funding, different communities of need began to open up.

Kufungisisa: Thinking Too Much

The Friendship Bench model is simple: Grandmothers are trained to provide support in the form of discussion before recommending further treatment for patients — in other words, curiosity followed by tangible action. Treatment options include 1-to-1 care or peer support circles. Yet, as Dixon worked to make Friendship Bench a success, his confidence waned. Working in Zimbabwe was not without its challenges.

Locals resisted discussing mental health challenges or using words from the DSM-V. The word “depression” itself is stigmatized; they rely instead on a Shona word, “kufungisisa,” meaning “thinking too much.”

Government interference was a threat, too. Representatives labeled the work as either irrelevant or deleterious. Dixon was told they couldn’t set up within existing clinics because they were too crowded, and medical staff were too busy to help.

Moreover, with only six psychiatrists in the country at the time, getting people to appreciate the concept of primary care for mental health was difficult.

When the results of the first clinical trial came out in 2016, it showed that the grandmothers were effective, and the solution was working. Validation came through several sources, notably a cluster-randomized controlled study that showed the solution to actually be more effective than typical solutions offered, namely, consultation with medical staff at a clinic.

When they started in 2006, Dixon’s aim wasn’t to operate at scale. He purposely focused on the hyperlocal and making a difference in one life, then two. He was open to scale when the time was right, but that wasn’t his starting success metric. Much more important was to develop a profound vision for change based on scientific backing and solutions that worked.

Friendship Bench has approached impact measurement in a sophisticated way from the beginning, in part due to Dixon’s scientific training, which meant he defined success by real metrics — lives changed as a result of the interventions offered. Beneficiaries of the Friendship Bench process have shown improvement in other areas, like adherence to antiretroviral therapy and continuous employment. The positive effects of improved mental health care are many, and once these results were published, it was illogical not to scale. Suddenly, Friendship Bench was a broad public good, given high costs of traditional psychiatry, lack of access to services, and clear evidence that their solution was better.

By the time they celebrated the ten-year anniversary of their 2006 pilot, Friendship Bench was operating in 72 facilities around Harare. Today, more than 100 scientific, peer-reviewed publications have proved that grandmother-led care is effective as a lasting treatment for depression.

Yet Dixon faced headwinds from a reluctant public and an interfering government. He suspected political agendas were behind many obstacles, because a few people who accessed Friendship Bench services had PTSD and said they had been tortured by state security forces.

As before, he leaned on the 14 grandmothers when things were tough. He drew on their strength and continued saying yes to opportunities that unfolded. The grandmothers became his support network, and Dixon says that, as with any social enterprise, it would have been impossible to do it alone. The grandmothers help keep him committed to this day.

Bringing a Bench to Every Community:

Dixon has been hands-on since the early days of Friendship Bench. He was involved in funding the nascent venture, and he was equally active in liaising with the grandmothers to ensure they had the resources they needed.

What started as a university research project soon progressed beyond the school’s scope, and he set up an independent trust that could handle operational decisions and provide board oversight. He brought in someone to oversee finances, and later, a COO. Friendship Bench formalized into an NGO as Dixon began to hand over some of his responsibilities. The board is now focused on scaling globally; registering as a 501(c)3 in the United States has made it easier to receive funding from US donors.

Dixon’s activities today are threefold: growing Friendship Bench, telling the Friendship Bench story, and fundraising. The emphasis on storytelling has grown recently, shaped by his experience in the Aspen Institute New Voices Fellowship, and this has become key in expanding reach. The fellowship helped him realize the power of narrative change and its role in driving scale. For social impact entrepreneurs, effectively telling a story on a strategic platform at the right time is an important component of success.

As enterprises scale, founders can become removed from onthe-ground work as other demands on their time emerge, but Dixon intentionally keeps himself connected. When the team at Friendship Bench considers a new partner, they follow a process of their own devising called the Suitability Checklist, comprising three key questions: 1) Is the potential partner in alignment with Friendship Bench’s mission, vision, and values? 2) Does the partner have the capacity to meaningfully take up the work with Friendship Bench, including supervision and monitoring of outcomes? 3) Do they have sufficient financial support?

Dixon has emphasized that he doesn’t walk alone. He has strong family support, he has strong team support, and he has the original grandmothers. He keeps himself connected to this resilienceenabling community.

He is still tangentially involved in research efforts through his work as a professor in both Zimbabwe and the U.K., and between all of it, Dixon has built a large team of people he can trust, beyond the original 14 grandmothers.

Before he had the team in place, Dixon says he relied on three pillars, which he terms the spiritual pillar, the physical pillar, and the intellectual pillar. By nurturing each, he could persist in the face of considerable headwinds, both administrative and societal.

The Friendship Bench team has met every Tuesday afternoon for ten years in a peer-led support circle called Kubatana Tose. Dixon attends regularly, and if he’s traveling, he often calls in to join. The cadence of meetings with the community has kept him grounded through many ups and downs.

Building a solid team has also been a process of letting go, but that’s not an idea Dixon fears.

“You have to be passionate about what you do,” Dixon says. “Because if you are passionate, it’s easy. I find that because I have such love for the Friendship Bench work, and I’m seeing it growing and growing. When the time comes, I feel I can let go of Friendship Bench, let somebody else run it, and I’ll still have relevance in some way.”