Episode 07: The Wisdom of Grandmothers

Dr. Dixon Chibanda.

Illustration by Alexander Bustamante

In episode seven, Maytal meets Dr. Dixon Chibanda, a psychiatrist from Harare, Zimbabwe. Dixon is the founder of the Friendship Bench, an organization that trains grandmothers in Africa to deliver evidence-based therapy on park benches. For Dixon, getting the Friendship Bench off of the ground wasn’t always easy - in fact, it initially incited a lot of resistance from the medical community. In today’s episode you’ll learn the story of how Dixon fought through the skepticism and transformed the Friendship Bench into a program that is widely revered across the globe.

Transcript:

Maytal: This episode of Heal With It contains information about depression and suicide. Listener discretion advised.

Maytal: Hi, I’m Maytal, and welcome to Heal With It, a podcast about healing in its many, and sometimes unexpected forms.

[Clip: Woman singing]

Maytal: 14 years ago, in 2007, a man named Dixon Chibanda created a program called the Friendship Bench. His mission was to reshape the world of mental health as we know it.

Dixon, an MD and psychiatrist, had always harbored doubts about the mental health care system. But it wasn’t until he met his patient, Erica, that he decided “enough is enough,” and that it was time to create a revolution.

Dixon Chibanda: Erica was a 26 year old, um , Zimbabwean, you know, very progressive young lady who was under my care for depression. And Erica lived, you know, some 300 miles away from the hospital where I worked and she would come and see me initially every month. And then later on, it was like every three months together with her mother. And one evening I got a call from the ER where she lived. And the doctor told me that Erica had taken an overdose, you know, she had taken an overdose, but she would be stable. She would be fine. And, you know, we agreed over the phone that as soon as Erica was stronger, she should come to Harare where I live and I probably would need to admit her and take care of her until she was feeling much better. 

And so I expected that to happen, say in about two weeks, you know, from the time she was admitted, but you know, after three weeks I heard nothing. And then, you know, one day I get a call from Erica's mother telling me that Erica had actually taken her own life. She had hung herself in the family garden from a mango tree, and, and my knee-jerk response at the time was almost in a very accusatory manner, was to ask Erica's mother why they didn't come to the hospital as we'd planned, you know, cause we planned that as soon as she left the ER, they would come to me and her response was we didn't have, you know, the $15 bus fare to come to you. And I think it was the statement - that statement, we didn't have $15 bus fare to come to you. That just hit me so hard, you know? I think that was like this massive realization, all of a sudden I'm like, here I am in my little castle in this hospital expecting everybody that needs my services to come to me. Yeah. And that was a turning point. And that's why we've taken it to the bench, a park bench, a wooden park bench.]

Maytal: A wooden park bench. This is at the core of The Friendship Bench. After experiencing the loss of Erica, Dixon decided it was time to create a new model of mental health, one that was integrated into his community, rather than siloed away, inaccessible to the people he cared about. 

And so with this new model, what he decided is that he would train grandmothers. 

[Clip Insert: Dr. Dixon Chibanda’s TED Talk 7:13 - 7:54]

By teaching grandmothers to deliver evidence-based therapy on park benches beneath the African sunlight, Dixon offered the community of Harare somewhere to go, someone to talk to, and above all, an accessible way to heal.

Now, fourteen years later, The Friendship Bench is widely accepted by the medical and mental healthcare community as revolutionary and remarkable. And better yet, the program is being replicated in countries across the world.

Today, you’ll learn the story of how Dixon was able to get this program off of the ground, even when the medical community around him insisted that it would never work. 

Dixon is inventive, hyper intelligent, and holds ideas that have the potential to change the world. I can’t wait for you to listen to this interview. So let’s get started. 

[Music Interlude]

Maytal: Maybe let's start today with the most obvious question. And that is about the friendship bench. So what is the friendship bench? What is its mission? How does it work? 

Dixon: Great question. Great starting point. The mission of the friendship bench is to take people out of depression. In essence, it is a brief psychological therapy delivered by trained community grandmothers who are essentially empowered with basic skills of what we call cognitive behavioral therapy. You know, the ability to bring together our feelings, our thoughts, and our behaviors and how that cycle can influence how we live our lives. And so friendship benches are essentially all about that, but delivered by grandmothers on wooden park benches in communities, across Zimbabwe and a couple of other countries. Um, so in a nutshell, that's what it is. 

Maytal: Brilliant. I'm curious more of the details, like how are the grandmothers trained, which benches do they sit on? How is that decided like more of the process of how this all works? I'm so curious. 

Dixon: So the grandmothers are trained over a one-month period. Typically what we do really is we identify suitable trainers in communities and we train them to become trainers. They then go on to train grandmothers in their communities. Our core friendship bench team facilitates the making of, or the manufacturer of wooden benches, depending on where we are in these communities. And each grandmother is allocated a wooden bench in her community. We then also facilitate awareness through social media radio programs so that people can actually visit the benches and the grandmothers then provide therapy. Uh, initially they screen everyone coming through the bench to identify those who are genuinely sort of depressed or have a condition that would benefit from a structured evidence-based therapy. After four to six sessions, people are then referred to join a support group in their communities. And that cycle just sort of carries on and, you know, recently due to COVID, a lot of our training has become kind of really blended where we use WhatsApp voice notes in a lot of other virtual platforms to actually train trainers and to train the grandmothers. Before COVID it was all entirely face-to-face. So, you know, we're increasingly moving towards digital platforms for both, um, delivery, but more so for training. 

Maytal: What was it about grandmothers? Why did you decide I want to train grandmothers to do CBT with community members?

Dixon: Grandmothers are considered to be the custodians of local culture and in wisdom, but, uh, but I'll tell you one of the things early, during my career, as a psychiatrist, I worked quite a lot with the world health organization as a consultant. And, um, it was during one of my consultancy when I was in a country called Benin specifically in a town called Ouidah where I experienced first hand elderly women or voodoo priestess, you know, as they're called carrying out a voodoo ceremony, which was part of a healing process. And this was really my first realization of the power of, of elderly women in African culture in general. And I guess that was the first little seed that was planted. And then when I went back to Zimbabwe, obviously a lot of other things happened - not to mention, you know, the death of my own patient through suicide and a lot of social economic upheavals in the country. 

All of that sort of directed me towards the single most important resource that was available in our communities: grandmothers. And I think to some extent it was influenced by, by what I saw in Ouidah, but a lot of other factors, including earlier experiences when I was, you know, when I was at medical school, like Dan, you know, um, somebody that I was pretty close to taking his own life. So there've been quite a number of events, you know, that have happened in my life that have contributed to some of the decisions that I've made, including starting friendship bench. 

Maytal: Yeah. I think what's been really interesting about this podcast is I talked to so many people and what seems to be a theme is that witnessing pain or experiencing your own pain or loss can often lead to figuring out these new, innovative ways of healing. And so I love to talk more about that, but before we go there, it's really interesting to me what you said, how grandmothers are one of the most important best resources we have. I want to hear more about that. Like, what is it about grandmother? So they're very revered in African culture, as you're talking about, what else makes them such a rich, incredible resource when it comes to healing?

Dixon: Grandmothers are rooted in their communities. I found over the years that grandmothers are a lot more willing to give back to their communities. And it seems almost as if by giving back these grandmothers become stronger themselves. You know, one of the areas that we emphasize within Friendship research, so everything that we do is well researched. You know, we have well over 50 peer reviewed publications on the work that we do within Friendship pension. One of the things we've found with the grandmothers is that, you know, a colleague of mine carried out this research as part of a PhD where she actually looked at the prevalence of common mental disorders amongst grandmothers in general. And compared those grandmothers who were within Friendship Bench versus those who were not in friendship. And these were similar grandmothers, you know, similar social demographic characteristics. And, and what she found was that the grandmothers who were working within Friendship Bench, who were giving back to their communities had much lower rates or prevalence of, uh, of common mental disorders, despite living in the same environment, which was quite traumatic and full of numerous stressors. What I think happens here is that the grandmothers by doing the work that they're doing, they in turn are getting healing because a lot of these grandmothers have experienced a lot of trauma in their own lines. And by providing this service to other people who are traumatized, they are finding healing in that process. 

Maytal: Yeah, that's absolutely genius. It's a two way healing approach. The people who are coming to the grandmothers are healing, but the grandmothers themselves are healing through the process. That's brilliant because yeah, I think about, you know, over here in the U.S. where I think the elderly are less valued, I think there's more age-ism here, I guess that leads to high levels of depression, anxiety, mental health issues among the elderly. So it's interesting to think about putting them in such an important, valuable, giving-back position. 

Dixon: Yeah. And you know, one of the other things that we're doing as we move increasingly towards using digital platforms, the grandmothers obviously are not extremely good at that. They need a lot of training and holding hand, so to speak, but, you know, lately we're pairing the grandmothers with young people, and we're seeing this very powerful intergenerational connectedness where these young people are empowering the grandmothers with these basic technological skills. So they can collect data for Friendship Bench and upload that data to our central database. And the young people in turn are becoming a lot more grounded and beginning to see the value of contributing to their own communities and playing a role towards building cohesion within the communities. And so we are seeing this increased sense of belonging amongst young people. And within the grandmothers there there's this purpose, you know, they see themselves as providing a service, not only to people coming to the bench, but also to the young people that they are working with, who become more grounded and give back a lot more to their community. So it's a win-win for all who are involved, you know, quite powerful, I think. 

Maytal: Absolutely. Probably. I mean, I have the chills over here just hearing about it because it's, it seems like it was such a good idea and then it was executed and so many values came out that maybe weren't even necessarily foreseen. And it's cool now, because, you know, I've read your research on nature. Like it's super impressive. It's highly evidence-based, but I'm curious, how did you start this? Was it a difficult thing to start? Like, was it an idea that you just tried with one study or how did you get this idea off the ground? 

Dixon: So to be quite honest, it wasn't planned the way it seems right now, because when we started, or rather when I started at the time, it was really, as I said earlier on almost a knee jerk response to the crises that were happening, you know, the, the multiple crisis losing Erica. And I talk extensively about Erica in my TED talk, the loss of Erica, you know, just brought about this sense of emptiness and the need to just, you know, explore and soul search, to find what my role really was as a psychiatrist in Africa. Did I want to remain working in a psychiatric hospital and expecting people to come to me for services? Or did I really want to take my services to the community? Because the vast majority of our people actually have no access to the services we provide in the hospitals. You know, so there was that.

And then obviously there was also, you know, um, these lingering thoughts about what I had seen in Ouidah and also the loss of someone who was quite dear to me when I was a medical student and then the crisis in the country, you know, has involved. We at the time were going through a massive upheaval, you know, the government had embarked on a cleanup operation, which resulted in over 2 million people being left homeless and psychologically affected. And that only came to an end after the United Nations at the time, secretary general Kofi Annan intervened. And, you know, in the midst of all of these scales, I suddenly realized there was a need to do something, something very different. And naturally there was a lot of, uh, resistance, you know, uh, the whole idea of trying to provide therapy on a bench with some random grandmothers who had very little education was, um, was not seen in good light both by colleagues and, um, others in the health services. So there was quite a lot of resistance initially, and this is why when I first started Friendship Bench, it was really supported out of pocket. I used part of my, you know, government, uh, salary as apsychiatrist to support the first, the very first 14 grandmothers that I worked with. And, you know, as they say, the rest is history. 

Maytal: How are you able to push through the resistance, the skepticism, the doubt from the other healthcare professionals? 

Dixon: I think it's because of my passion for what I was doing, you know, when you have a passion for something, and you feel that energy from, from doing the work that you're doing, you know, despite the resistance around you, it almost as if that works, you feed off of that work, that that work gives you a sense of purpose. And that's why I carried on. 

[Music Interlude - “More with Dr. Dixon Chibanda after this short break.”]

Maytal: So something I really learn from is stories. And I'm curious to hear of a story of maybe with one of the grandmothers, are you witnessing something really impactful occurring with the Friendship Bench? 

Dixon: One of the oldest, in fact, she is currently the oldest grandmother on Friendship Bench. Her name is grandmother Weezer, which literally means grasshopper. She has the most fascinating story. Zimbabwe was previously a Rhodesia. So when she was growing up, when the country was still Rhodesia, you know, we, we lived in a, in a country where there was segregation. It's essentially a form of apartheid, you know, where blacks lived, one side of town and the whites lived on the one side. And, you know, so that really did cause quite a lot of friction. And, um, it was because of the fact that, you know, black people had no rights in the country that we ended up having this civil war where, um, a lot of people lost their lives, both Blacks and whites, and grandmother Weeza was one of the freedom fighters. 

And she was responsible for carrying out one of the most significant attacks on a fuel storage system or plant in the country. And she narrates her story, you know, how she was involved in all of that. And then how she subsequently was arrested. They picked her up, they figured out that she was the one who was involved in blowing up this fuel plant. And she went through, uh, a terrible time of essentially, you know, torture and she narrates her story and what she went through. But the beauty of her story is that it took her all these years until, you know, she joined Friendship Bench to realize the value of healing others, because she, I believe she has suffered from post-traumatic stress disorder as a result of, of what she went through. But, you know, and for a long time, she always talked about these recurring nightmares. Um, you know, of flashbacks of what happened to her when she was incarcerated, when she was tortured and, and also, you know, what she did, you know, when she looks back, you know, in hindsight, she feels, it wasn't really necessary to do what she did, but, you know, coming to Friendship Bench, she brings this wealth of wisdom and just this sense of stability and need to build cohesion in communities. But on top of all of that, she's, she is healing. And over the years, you know, it's, she's, she's been having, I think she's had chronic post-traumatic stress disorder in essence. And, you know, it's only recently, you know, the past couple of years that those flashbacks, those recurrent nightmares have stopped, you know, and she attributes all of that to the healing that she herself has received and being able to give to others through the stories, you know, the stories that come to the friendship bench, because, you know, we often talk about friendship bench being this evidence-based intervention, but in essence, it's really about storytelling. 

What happens on the bench is that the grandmothers create this space for people to share their stories. And as people share those stories, the provide a structured way of addressing the challenges that are within those stories. But the beauty of listening to a story is that it can touch you the listener as well. Not just the person telling the story, the listener is touched profoundly. And just the process of being in the presence and listening to a story has tremendous therapeutic value. And we see this every day when grandmothers listen to these stories, and then they meet me to give a debrief of what they heard. You can see how it's touched their lives, you know, and so, uh, I think this is one of the beauties of Friendship Bench, which actually, you know, kind of removes the whole idea of a clinical model because at face value, it's about stories. Although it's rooted in science.

Maytal: Something that's really striking to me about what you're talking about is how by healing others, people heal themselves as in the case of the grandmothers. And I just can't help, but think that this has larger implications for mental health in general. I mean, right now the model is you go to a trained therapist  in their office who you go to most of the time to receive therapy. But what if we were training other people in communities - other integral community members, depending on the culture or the geographic location or whatever it is - to do this kind of work? I mean, that could be really shifting. And I'm curious what your thoughts are on that. 

Dixon: That would be, I mean, to some extent that's beginning to happen, but not in a big way. We, you know, there's, there's overwhelming evidence right now, which shows that non-professionals can be trained to treat a whole range of, uh, DSM-V conditions. You know, particularly what we call common mental disorders, and they can contribute significantly to narrowing what we call the treatment gap. And I think ultimately it's, it's all about our capacity to make people feel respected and understood. And that's really what empathy is all about. And I think you don't need a hell of a lot of training to learn how to be empathic, to learn how to respect and understand other people, because this is what the grandmothers do, you know, initially on the banks, you know, they give space and respect and make people feel understood. That's very powerful. It's really powerful. 

Maytal: Someone else I had talked to on this podcast works with barbers in different cities across the country and teaches them basic listening skills. You know, it's like you said, it's empathy. We all have it. We all have the capacity. It doesn't take, you know, a degree to teach someone how to be empathic, but he teaches barbers to do similar work. And I think it's, again, it's sort of this like peer to peer counseling model. And I think it just makes getting help and healing way more accessible than the traditional models do. 

Dixon: Yeah. Yeah, indeed. 

Maytal: So something we talked about before was your story and what led you here? I know you brought up the suicide of a friend. I wanted to hear more in depth. Just your story again. Like what led you to wanting to be someone in the field of mental health and the field of psychiatry in the field of healing? What brought you here? 

Dixon: Well, you know, like, like I said earlier on, you know, I think there's no one single reason. I think it was a number of events which happened, you know, not necessarily at the same time, you know, and I think of my, my childhood, you know, my parents, my parents divorced when I was pretty young and, uh, that left a profound, you know, sense of, I don't know, angst, you know, if you want to call it that at the time. And I think I became a lot more sensitive in general to other people around me, what they were experiencing. And I just became a lot more attentive and, and going to medical school and being exposed, you know, I was in the Czech Republic. That's where I started my medicine and being exposed to a completely different culture where you are immersed in a society where there's a lot of, um, racism, you know, because you look different and you begin to appreciate people who recognize you for what you are, and you tap into those inner strengths and you begin to connect a lot more with people because it's almost like there's adversity everywhere around you. 

And then, you know, the death of this colleague while at medical school, again, that left a profound sense of loss. But at the time, I obviously was not thinking of studying psychiatry. I think my number one sort of a priority or focus at the time was to become a pediatrician or dermatologist. And when I got back to Zimbabwe, I think just seeing the suffering and then the work that I was doing with the world health organization, you know, all of that really exposed me a lot more to mental health. And I, I realized the need to just, you know, take mental health to the community, make, make it accessible because in Africa and in a lot of countries, actually not only Africa, the world over there's this misconception that people who have psychological or mental disorders need to be in a facility, they need to go somewhere where trained specialists can take care of them. 

You know, I actually think that a lot of them would benefit a lot more by talking to someone empathic in their community. Someone who makes them feel respected and understood that in itself has profound healing effect. You don't have to see a psychiatris. And the other thing as well, you know, uh, working in psychiatry as a medical doctor, I was troubled by the use of medication, and just watching people walking around like zombies, you know, drugged up and all of that - the quality of life can be terrible. I'm not saying medication is not important. I mean, I think there's room for medication. I mean, after all, I'm a medical doctor, I do prescribe, uh, I don't want you to get me wrong there, but I also think that I really do believe that human stories can be profoundly therapeutic without medication, if provided in the right way, by the right person in the right dose, it can be powerful. And this is what we see in Friendship Bench, you know, with the grandmothers. 

Maytal: The storytelling is the medicine within itself. I'm so inspired by what you're saying, because I just can relate. Um, I just finished my PhD in psychology and I think throughout the whole PhD and more so actually towards the end, I just kept seeing there's these certain ways to do things. And then going outside of that box is almost looked down upon. And it just, I don't agree with that. I think there are different new models to approach therapy and healing that go outside of psychotherapy and psychotropic medication. And that's why I just think what you're doing is brilliant. 

Dixon: You know, it's, it's interesting. You brought up that subject, you know, and we, we've often battled with the whole idea of, because, you know, when we publish our work, we have to use the Western model as the gold standard, but we're increasingly realizing that, you know, a lot of what is considered to be the gold standard might not really apply in this part of the world, particularly for a lot of clients that come to the bench, for instance, the notion of having X number of sessions before you see an improvement, you know, if you have a single session which profoundly touches your life, you know, and profoundly shifts the way you see your world, your cognitive approach, reappraisal, as they call it, this cognitive reappraisal can happen within a single session. You don't need six, 12 sessions. And we see this constantly on the Friendship Bench where people spend an hour with a grandmother and they're like, no one has ever spoken to me the way that this grandmother spoke to me. And it has profoundly changed the way I view myself and the problems that I'm currently facing. So these, these are some of the newer things that we really need to be looking at. You know, I, I strongly believe that sometimes a single session is as therapeutic as six sessions. 

Maytal: This is really fascinating to me. And it segues perfectly into my next question, which is, what do you feel like the mental health field as a whole is getting wrong or, or maybe a better question for you is what do you feel like the mental health field as a whole could be doing better? 

Dixon: I think there are many different ways of addressing the, the huge treatment gap that currently exists globally. What we're getting wrong is this misconception or assumption that models developed in the Western world are the only models that we can use to, um, to address, you know, um, mental health issues. You know, for instance, when you look at the role of traditional healers, uh, in, in most low middle income countries, I think they could be trained to play a significant and important role in addressing certain mental health issues, because the approach they use is culturally accepted. Yes. Sometimes the approach they use can lead to harm, but I think by engaging them, by getting them involved, we can reach some kind of common ground and there is some evidence, you know, there's work from Nigeria which shows how, you know, traditional healers can be, can be trained to contribute towards the management of people with psychosis, for instance, which is really very important. 

And also it's, it's also the, the whole obsession with the DSM-V, I think. And, in the ICD 10 where we try to put people in, in these categories, you know - you're bipolar, you're this, you know, you're schizophrenia, you know, um, people are a lot more complex than that. I think that's also contributing to some of the challenges. So, so I really think, although I do feel positive about the future, you know, I think we need to think a lot more outside the box in terms of how best to bring mental health, that is evidence-based, but that is also culturally and contextually relevant for the different populations that we work with. 

Maytal: So well said, what would you like the future to look like? You said you feel positive about it. What do you envision? 

Dixon: So I envisioned for the work that I do, I envision, you know, a Friendship Bench within walking distance for everybody. But, um, having said that, I think there are numerous other programs out there that are doing similar work to the Friendship Bench. So I generally would like to see a lot more, non-professionals playing an active role in addressing mental health issues in their communities. 

Maytal: I am like aggressively nodding my head because I'm in such high agreement with you. I, I believe that so much. I think that's the future final question. If people want to learn more about you, cause I know they will, after listening to you today, where should they go? Any specific websites, social media, anything you'd like to share? 

Dixon: So we have, you know, we have a friendship bench website, you know, it's www.friendshipbenchzimbabwe.org, or you can go to my LinkedIn and it's Dixon Chibanda and you can see everything about my work and what we're doing currently. You know, we are at the moment, very busy preparing for World Mental Health Day in October, you know, so watch this space, a lot of interesting things that we will be launching to commemorate world mental health day.

Maytal: Awesome. Thank you so much for being here today for talking. I learned so much. 

Dixon: Thank you.