Case 8.3 Grandmothers and Benches

The invitation of a park bench and the compassion of a grandmother are saving lives in Zimbabwe.

Zimbabwe, an African nation of more than 16 million people, had only 12 psychiatrists available to meet

the mental health needs of the entire country. Dr. Dixon Chibanda is one of them (Chibanda, 2017c;

Nuwer, 2018).

After losing a young patient he had treated for depression to suicide because she and her mother could

not afford the $15 bus fare to come to his office for treatment, Dr. Chibanda realized that the traditional

delivery of mental health careoffering services in a facility and waiting for patients to come to him

would not work in his country. After much soul searching and consideration of the effectiveness of his

role as a psychiatrist in Zimbabwe, Dr. Chibanda had an epiphany.

Suicide is not unusual when it comes to mental health concerns. According to the World Health

Organization (WHO), suicide is the leading cause of death of those ages 15 to 29 worldwide. Globally, more than 300 million people suffer from depression, according to the WHO. Depression is the worlds

leading cause of disability and contributes to 800,000 suicides per year, the majority of which occur in

developing countries (Nuwer, 2018).

Depression, often the result of loneliness, abuse, conflict, and violence, is a treatable mental illness. But

treatment needs to be available and affordable, which are large concerns for a country like Zimbabwe

with extremely limited resources.

In 2006, Dr. Chibanda began leading a team of Zimbabwean researchers in testing new ways of

addressing anxiety and depression disorders and making treatment accessible to those who need it

(Chibanda, 2017a). With no money or facilities available, he accessed the most abundant and reliable

resource he could think of: grandmothers. Thus, the Friendship Bench approach was conceived.

The Friendship Bench involves the engagement and training of laypeoplegrandmothers, to be precise

from local communities, as well as the integration of digital technologies.

Why grandmothers? Grandmothers are often a trusted, cultural cornerstone in Zimbabwean

communities. It suddenly dawned on me that actually, one of the most reliable resources we have in

Africa are grandmothers. Yes, grandmothers. And I thought, grandmothers are in every community.

There are hundreds of them (Chibanda, 2017c).

In addition, Dr. Chibanda realized that grandmothers, unlike many younger workers, were more likely to

stay in place and not leave the communities to seek other opportunities. Furthermore, many

grandmothers were already doing community work, and association with this program would reinforce

their role in the community.

When we started, we didnt know what the core competencies were . . . Later we discovered that our

lay therapists needed strong listening skills, an ability to convey empathy and an ability to reflectall

skills the grandmothers had and could develop further (WHO, 2018, p. 377).

Training these community counselors involved the application of basic cognitive therapy (often referred

to as talk therapy) concepts. The grandmothers were taught to adopt a nonjudgmental and practical

approach, allowing the clients to discuss their challenges and talk through possible solutions. Dr.

Chibandas strategy was to empower them [the grandmothers] with the skills to provide behavior

activation, [and] activity scheduling; and support them using digital technology. You know, mobile phone

technology. Pretty much everyone in Africa has a mobile phone today (Chibanda, 2017c).

The program launched in 2007, and Dr. Chibanda spent the first four years of the program working with

14 grandmothers and his colleague, Petra Mesu, to develop a culturally appropriate and evidencebased intervention they could deliver (WHO, 2018, p. 377). Together, they developed a therapy focused

on problem solving that incorporated the native Shona language and familiar, local cultural concepts.

The first step of the program is screening, which is done at a health facility. Using a locally developed

diagnosis tool called the Shona Symptom Questionnaire, clients are evaluated as to whether they are

suffering from mental illness and what form of mental illness. If it is found that they are, then they are

referred to the Friendship Bench where they meet with one of the trained community counselors (the

grandmothers). The Friendship Bench is a literal wooden park bench, initially located in discreet areas

around the health facility, where patient and grandmother (counselor) can openly discuss a patients

concerns in a comfortable setting. Due to the growing acceptance of the program, these benches are

now more publicly visible.

As part of their training, counselors are taught to use language and terms familiar to their clients such as

kuvhura pfungwa (opening the mind), kusimudzira (uplifting), and kusimbisa (to strengthen). Many

of the clients suffer with depression, which is commonly referred to as kufungisisa (thinking too much)

in the Shona language.

They provide six sessions of individual problem-solving therapy to each patient and refer those at risk

of suicide to their immediate supervisors. The first session takes an hour or more, during which the

grandmother listens, establishes a rapport with the client, and takes notes. Their notes are reviewed

regularly by the team, together with the grandmothers, particularly during debrief sessions. The sessions

are recorded for their supervisors to monitor, said Dr. Chibanda. Afterwards, the grandmother reflects

on what the client said and decides what needs to be done with the other grandmothers. Subsequent

sessions with the client can be quite short, 2030 minutes, because the client has an understanding of

what to focus on (WHO, 2018, p. 377).

Technology plays an important role in the program. To store patient data, the team uses a secure

platform combined with cloud computing. Each patient receives text messages between sessions to

encourage their problem-solving efforts. When a client does not turn up for a session on the bench, we

call them and if there is no response, the grandmother and a health professional visit the clients home,

Dr. Chibanda said (WHO, 2018, p. 377).

Dedicated to the success of the program, Dr. Chibanda ran the initial pilot in Mbare, using his own salary

to pay for supplies and space rental for the training. The program would eventually receive funding from

the National Healthcare Trust, Zimbabwe and other organizations.

Some of the grandmothers are paid, receiving an allowance from their citys health department. During

the clinical trials, funding was available, but once those trials concluded, that funding dried up and Dr.

Chibanda was concerned the grandmothers might cease working. To his surprise, they did not. When he

and his colleagues looked into why, they found the grandmothers exhibited negative mental health

conditions of their own, and the team hypothesized that perhaps the work the grandmothers were doing

helped them as well, enabling them to expand their own well-being and resilience to adversity.

Dr. Chibandas own mother came up with the income-generating model for the grandmothers. After

finishing sessions on the bench, the grandmothers sit in a circle and share the challenges they face with

their colleagues, while crocheting bags with recycled plastic to sell. Now, after completing therapy, the

grandmothers give their patients further support and show them how to make the bags. So, this is a

forum for problem solving and income generation (WHO, 2018, p. 377).

The success of the program speaks for itself. In 2017, the program had been scaled into more than 70

communities, with hundreds of grandmothers providing mental health services in those communities.

More than 30,000 people have received treatment on the Friendship Bench. Our resultsthis was a

clinical trialin fact, this clinical trial showed that grandmothers were more effective at treating

depression than doctors (Chibanda, 2017c).

When we compared the Friendship Bench approach to standard care, plus information, education, and

support on common mental disorders, we found that after nine months the Friendship Bench patients

had a significantly lower risk of symptoms than the standard of care group, Dr. Chibanda said (WHO,

2018, p. 377).

Not surprisingly, Chibanda sees the potential in expanding the program globally. Even in developed

countries, the availability of mental health professionals is rapidly declining, with waiting times to receive

care increasing to dangerous levels. In the United Kingdom, thousands of people attempt suicide while

waiting, sometimes for months, on the National Health Service list to see a psychologist. Similarly, long

waiting lists have been reported in the United States (Chibanda, 2017b).

Dr. Chibanda notes that today there are more than 600 million people worldwide who are above 65, with

this number expected to expand to 1.5 billion people by the year 2050. He envisions a global network

of grandmothers in every city in the world who are trained in evidence-based talk therapy, supported

through digital platforms, networked. And they will make a difference in communities. They will reduce

the treatment gap for mental, neurological and substance-use disorders (Chibanda, 2017c).

The realization of this vision has already begun. The program has expanded to rural areas in Zimbabwe

and is developing a component for adolescents. The Friendship Bench approach is being implemented

in Malawi with plans for it to be used in Zanzibar, United Republic of Tanzania. Its use is even being

explored in the United States, Canada, Australia, and New Zealand (WHO, 2018, p. 377).

Questions

1. Based on the definition of transformational leadership in this chapter:

a. What aspects of the implementation of the Friendship Bench and the effectiveness of the

grandmothers do you see as related to the transformational leadership processes? Explain

why.

b. Are there aspects of this process outlined in this case study that you would classify as

transactional leadership? Why?

2. Charisma and its relationship to transformational leadership was discussed at length and outlined in

Table 8.1. View Dr. Dixon Chibandas 2017 TED Talk at

www.ted.com/talks/dixon_chibanda_why_i_train_grandmothers_to_treat_depression and respond

to the following:

a. Do you perceive Dr. Chibanda to be a charismatic leader? Why or why not?

b. What about the grandmothers? What characteristics of charismatic leadership, if any, would

you ascribe to them? Explain your answer.

c. Bass suggested that charisma is a necessary but not sufficient condition for transformational

leadership. Based on the elements of this case study, would you agree or disagree? Why?

3. How do each of the leadership factors of idealized influence, intellectual stimulation, and

individualized consideration relate to this case?

4. Bennis and Nanus expanded on the transformational perspective by identifying four common

strategies for transformational leaders. Discuss how each of these relates to Dr. Chibanda and the

grandmothers:

a. Clear vision

b. Social architect

c. Creation of trust

d. Creative deployment of self

5. Kouzes and Posner identified five fundamental practices of transformational leaders. Discuss how

these apply to this case:

a. Model the way

b. Inspire a shared vision

c. Challenge the process

d. Enable others to act

e. Encourage the heart

6. The chapter lists seven criticisms of the transformational leadership model. Select three of these

and address them with respect to this case.