Rethinking Mental Healthcare on the Friendship Bench

What makes someone feel safe enough to ask for help? For someone experiencing depression or anxiety, that answer may depend on who offers care and how it is provided. In Zimbabwe, the Friendship Bench brings psychological support to wooden benches outside primary care clinics, where trained community health workers help patients work through their worries and concerns [1]. Many community health workers consist of older women whom patients tend to call grandmothers, and their role raises an important question for medicine: how can community relationships become part of effective care [2]?

BRINGING MENTAL HEALTHCARE INTO THE COMMUNITY

The Friendship Bench was developed specifically to target gaps in access to mental healthcare. Its workers use problem-solving therapy to help patients identify their most pressing concerns and develop practical steps to address them [1]. Patients then take an active role in deciding what to do next. Through this approach, it places support within an already existing community setting while expanding who can participate in providing mental healthcare. It also encourages us to consider how the settings and relationships surrounding treatment can influence a patient’s willingness to seek help.

HOW CULTURE SHAPES LANGUAGE AND TRUST

Having a cultural understanding can shape even the language of care. In the Harare communities studied, kufungisisa, a Shona expression translated as “thinking too much,” describes emotional distress involving too much worry and rumination [2]. The program incorporated this language into its screening approach. Interviews also suggested that workers’ maturity, community standing, and shared life experiences helped establish trust; patients sometimes described them in familial terms [2]. These findings suggest that culturally responsive care can include recognizing familiar expressions of suffering and the various relationships through which people feel comfortable discussing them. A patient’s understanding of their distress deserves a place in the conversation about treatment.

WHAT THE RESEARCH SHOWS

Clinical research supports the program’s promise as well. A 2016 randomized trial enrolled 573 adults across 24 clinics in Harare. After six months, 13.7% of participants receiving the Friendship Bench intervention met the study’s threshold for depressive symptoms, compared with 49.9% receiving enhanced usual care [3]. However, the study looked at a package that included problem-solving therapy and optional peer support, so it cannot suggest how much of the improvement came specifically from cultural familiarity [3].

SUPPORTING THE PEOPLE WHO PROVIDE CARE

Community caregiving also carries ethical responsibilities. A 2023 implementation study found that workers felt overwhelmed by complex cases and identified feedback and incentives as important to program delivery [4]. The model includes supervision and referral pathways for people needing a higher level of care [4]. Communities contributing their knowledge and labor deserve consistent investment in training and support. Recognizing the value of these workers should also include making sure they have the resources to care for others safely.

LESSON FOR HEALTHCARE AROUND THE WORLD

The Friendship Bench offers a perspective on medicine in which clinical methods and community relationships coexist. Other healthcare systems can learn from its attention to whom patients trust and how they describe suffering. Adapting that approach requires listening to the communities a service intends to reach. When a patient’s cultural knowledge helps shape care, medicine can become more approachable for the people it serves.

Designed by: Poorvaja Chandramouli

Reviewed by: Gage Gruett

References

{1] Chibanda, D., Bowers, T., Verhey, R., Rusakaniko, S., Abas, M., Weiss, H. A., & Araya, R. (2015). The Friendship Bench programme: A cluster randomised controlled trial of a brief psychological intervention for common mental disorders delivered by lay health workers in Zimbabwe. International Journal of Mental Health Systems, 9, Article 21. https://doi.org/10.1186/s13033-015-0013-y⁠

[2] Abas, M., Bowers, T., Manda, E., Cooper, S., Machando, D., Verhey, R., Lamech, N., Araya, R., & Chibanda, D. (2016). ‘Opening up the mind’: Problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the Friendship Bench Project in Zimbabwe. International Journal of Mental Health Systems, 10, Article 39. https://doi.org/10.1186/s13033-016-0071-9⁠

[3] Chibanda, D., Weiss, H. A., Verhey, R., Simms, V., Munjoma, R., Rusakaniko, S., Chingono, A., Munetsi, E., Bere, T., Manda, E., Abas, M., & Araya, R. (2016). Effect of a primary care-based psychological intervention on symptoms of common mental disorders in Zimbabwe: A randomized clinical trial. JAMA, 316(24), 2618–2626. https://doi.org/10.1001/jama.2016.19102⁠

[4] Chitiyo, C., Verhey, R., Mboweni, S. N., Healey, A., Chibanda, D., Araya, R., & Wagenaar, B. H. (2023). Applying the Consolidated Framework for Implementation Research to optimize implementation strategies for the Friendship Bench psychological intervention in Zimbabwe. Global Implementation Research and Applications, 3(3), 245–258. https://doi.org/10.1007/s43477-023-00093-4⁠