For decades, many psychiatrists believed depression was a uniquely western phenomenon. But in the last few years, a new movement has turned this thinking on its head.
When Vikram Patel first began to study mental health, he believed depression only existed in rich nations. But today, he is the single most influential figure in the growing global movement to treat mental illness in poor countries, especially the most common disorder, depression.
One night in 2005, Chibanda got a call from a doctor in Mutare, a city south-east of Harare. One of Chibanda’s former patients, a 24-year-old named Erica, had tried to kill herself with rat poison. Chibanda asked the doctor to tell Erica’s mother to bring her to see him as soon as possible. He heard nothing for three weeks, then one day the mother called to tell him that Erica had hanged herself from a mango tree in the family garden.
“We didn’t have bus fare,” the mother said.
“I started to realise that psychiatry in an institution is not the way to go,” Chibanda recalled. “We have to take it to the community.”
He conducted a survey in 12 clinics around Harare, and found that the clinic with the highest rate of depression was in the slum of Mbare, where one in three people was affected. In 2006, he told the city health department he wanted to start a mental health programme there.
Neither the department nor the clinic staff were enthusiastic. “The clinic told me the nurses were too busy,” Chibanda said. “And there was no space for me to work inside the building.” So he set up a bench in the yard.
Grudgingly, the clinic lent Chibanda the services of its “Grannies” – middle-aged or older women with little education, who earn a small stipend doing community health work. The Grannies were given two weeks to learn what depression is, how to diagnose it using a simple questionnaire adapted for Zimbabwe by Patel, and how to do a form of problem-solving therapy modelled on an approach Abas had used in Harare in the early 90s.
To be able to treat large numbers of depressed or anxious people, any solution has to be cheap and easy to spread. It can’t depend on having an office or trained professionals. The goal, said Abas, was to teach people who are already working with the community how to treat depression. Grannies on a bench turned out to be perfect.
By 2015, every health clinic in Harare had a group of sturdy red wood benches in its yard, known as friendship benches, and grannies in brown uniforms who sat on them talking to patients each morning. The grannies use standard problem-solving therapy, but put it into terms people can relate to. They use Shona phrases for opening up the mind and strengthening the spirit. If patients want to pray with their granny, they pray. “We try to avoid dismissing what people believe in,” Chibanda said. “We say, pray, but in a way that encourages problem-solving: ‘God, help this person to identify which problem to focus on.’”
Israel Makwara, Harare’s chief health promotion officer, told me that the grannies made every other health programme in Harare go better. The clinics’ HIV programmes were one example. “If somebody’s frame of mind is now solid, they are likely to adhere to their medications,” Makwara said. “They’ll do a whole lot better than someone who has given up the will to live.”
At the Hatcliffe Polyclinic, in the north of Harare, very few people come to the clinic for mental health care, but the protocol is to offer everyone a questionnaire to screen them for depression. If they score high, they get an appointment on the friendship bench in the front yard.
In Zimbabwe, elders are used to simply dispensing advice, said Vongai Muchengeti, a granny at the Hatcliffe clinic. But encouraging patients to come up with their own solutions is an important part of the therapy; it teaches patients to think more critically, assess alternatives and gain confidence.
“How do you think you can resolve this?” Muchengeti kept asking one patient.
“I’ve come here for you to tell me how,” the patient replied. “You’re supposed to help me.”
“This is how I’m helping you,” Muchengeti said.
The ideas the patients do come up with – I could look for work, I could talk to my husband – might seem obvious, but they’re not to people with depression. “You have HIV, your teenage daughter is pregnant, your husband is abusive, you’re about to be evicted,” said Ruth Verhey, a German-born clinical psychologist who runs the programme with Chibanda. “That buildup leads to a sense of helplessness.”
The grannies help people overcome that. At the end of 2016, Chibanda published the results of a randomised control study in which he assigned 573 patients either to a bench or to a better version of usual care, including antidepressants when necessary. After six months, 50% of patients in the non-bench group were still depressed, while only 14% of friendship bench patients were.
Today, Zimbabwe has friendship benches at 72 health clinics in three cities. Verhey estimated that about 40,000 patients have been treated in the last two or three years, most of them women. Chibanda has also launched benches in rural areas, and one for adolescents, which will be staffed by their peers. The model is also being adapted in other places, from Malawi and Zanzibar to New York.
Verhey said people write from all over the world. “We get so many people saying: ‘I want to do this with my NGO, with my church group,’” she said. “My standard reply is that we like to work inside the health system. That way you have accessibility and sustainability.”
For all its profile, however, the programme has next to no money. Neither Chibanda nor Verhey are paid. The programme has funding for specific research projects – including, recently, a much-needed study of how grannies were actually delivering therapy. But there are no funds to spread the programme.
Even before the friendship bench programme was fully underway, Chibanda knew it also had to offer some solutions to patients’ most important problem: desperate poverty. He consulted an expert on how women in slums or villages could make money: his own grandmother, who lived in Mbare, where the programme began. She said many women make money by crocheting sleeping mats – could they crochet other things?
Verhey began collecting plastic destined for landfills, such as grocery bags and old videotapes, that could be shredded or unspooled and turned into yarn. Women visiting the benches used the yarn to crochet bags, purses, laptop cases and other items. They then sold the bags in local markets, while Verhey sold some in Zimbabwe’s high-end tourists shops and to other parents at Harare’s international school. A bag could sell for as much as $10 – more than three times the average daily income in Zimbabwe.
The crocheting project had a second purpose: treatment on the bench usually lasts for about six sessions. But the need for solidarity and companionship does not go away. Meeting to turn in their bags and get new materials gave women a reason to congregate. The programme created a support system for the women, called Circle Kubatana Tose, which means “hold hands together”. There was a circle in nearly every clinic.
I went to one circle in a small red building on the campus of the psychiatric unit at Harare Central hospital. Women came in with their latest crochet work and there was soon a heap of brightly coloured bags on the floor. They prayed, drummed, sang and shared their news. Their problems – domestic violence, alcoholic partners, HIV, hunger – were common in their neighbourhoods. But because of stigma, they were rarely discussed outside the circle. Neighbourhood life can be supportive and warm, rich with human connection. But it can also be dominated by gossip and judgment.
A woman named Tackla told me that when she was diagnosed with HIV, she was desperate to talk about it. “But I was frightened to talk to people because they might laugh at me,” she said. “And if you talk to a neighbour, they could tell everybody. So I kept it to myself.” The circle was the only place she could talk freely, she said. In her circle, she was the first to volunteer that she was infected. “When I did, another woman said she was, too. We talk to each other,” she said. “We are friends.”
The collapse of Zimbabwe’s economy is accelerating, and Verhey’s bag programme collapsed a year ago for lack of buyers. But the circles refused to fail. Women still gather at their health clinic or village well and sit and talk in a group they trust, and while they talk, they still crochet, or make shoes from rubber tyres.
Vikram Patel had gone to Zimbabwe in 1993 seeking to show that depression was a social and political condition, and that no clinical intervention was necessary. He convinced himself of the opposite: psychotherapy or medicine were all that was needed to cure it.
Now he has come halfway back around: you need both. About 80% of depressed people everywhere, Patel said, need only what he called a “hope intervention” – someone to guide them through self-help. That could be as little as a single session of counselling with a lay health worker. But it is also necessary to sit and talk to trusted friends in a circle. It is necessary to take a crochet hook and fashion old videotape into something that can allow you to feed your children.
“We have to redefine what is a psychological intervention, recognising that for many people, their psychological well-being is embedded in their social world,” Patel said. “It would be almost unreal for a psychological worker in India to say to a woman whose husband beats her: ‘That is not my concern. I’m only concerned with your negative thoughts.’”