A group of grandmothers sits in the garden in Harare’s Milton Park neighbourhood enjoying tea and listening attentively to a speaker. They are partaking in training, the first face-to-face session since the beginning of the global pandemic caused by COVID-19.
Usually, they would gather together indoors in the local community centres or primary clinics, or here at the Friendship Bench main office. But due to the pandemic the training takes place outside.
The organisation, The Friendship Bench, started in 2016 in the Mbare neighbourhood of Harare, Zimbabwe. Back then, there was a government operation to demolish illegal structures, such as extensions to residential homes or temporary stalls for vendors.
These structures – often occurring in poor high-density areas – were deemed illegal, because there were neither planning nor building permits acquired.
“A lot of people lost their homes or their businesses, which resulted in many of them going to rural areas, back to their family homes,” says Beatrice Chawira, a clinical supervisor and a trainer for the organisation.
Due to the destruction of the illegal structures and the resultant loss of housing and income, the incidence of depression was rising in the community.
The grandmothers, or gogos, as they are called in Shona, many of whom work in the primary health care clinics, noticed a rise in mental health problems. There was an urgency to act.
Professor Dixon Chibanda trained the first group of gogos in Mbare to offer the intervention. Today, The Friendship Bench consists of a team of directors, operation leaders and core team members such as project coordinators, house managers and clinical supervisors like Chawira, as well as research assistants.
The Friendship Bench also has external collaborators including professors of global mental health, epidemiology and epidemiological psychiatry.
Based on research and a community approach
But the key figures and the ones actively visible in the community are the gogos, who meet locals to discuss their concerns and stresses.
The gogos get trained over a period of two to three weeks on how to screen for mental health problems, and they get follow-up training sessions over the months to come. In their fieldwork, they use a Shona symptoms questionnaire (SSQ), which has 14 questions. The questionnaire is used to assess if someone is at risk of depression or is suffering from other mental health problems.
“After the assessment, they can see if a client has scored more than nine on the SSQ. That means they are at risk of depression,” Chawira explains.
In families, if you have problems, most people would go to their grandmothers for help.
The questionnaire has a few questions that immediately flag a mental health problem. If a customer replies “yes” to these, they immediately get referred to a professional, like a mental health nurse who will assess the risks further.
The questionnaire itself was adapted to Zimbabwe from a clinical mental health questionnaire model that included more than 50 questions. The model of questionnaire and the risk assessments by the gogos gets evaluated on a regular basis, as the gogos record all the sessions with the clients. These recordings then get listened to by the healthcare professionals in the team.
“After listening to these recordings, we can identify areas that still need developing,” Chawira says.
Behind the organisation’s approach is research such as a randomised clinical trial: Effect of a Primary Care–Based Psychological Intervention on Symptoms of Common Mental Disorders in Zimbabwe.
Gogos are easy to talk to
The Friendship Bench decided to train the gogos, because they are respected members of the communities.
“In families, if you have problems, most people would go to their grandmothers for help. Grandmothers are lovable and easy to approach,” Chawira explains.
The Friendship Bench has a very informal approach; the gogos often meet the clients within the community rather than at the health care facilities. This lowers the barrier for the locals to seek help, as mental health problems still carry a big stigma in Zimbabwe.
The gogos meet and sit with their clients outdoors, under the trees on wooden park benches in discreet safe spaces in the community.
The Friendship Bench keeps developing its operating model based on the recordings, the feedback from the gogos and from the clients.
Initially, the gogos had six problem-solving therapy steps they’d go through with the client at the first session. But as each client communicates differently and some take more time than others, the organisation decided that the gogos should only focus on a couple of steps during the first session – and continue with the next steps during the following appointments.
Some of the grandmothers are mobilised to walk in the communities to talk about mental health and self-care. They teach the locals that they have to have time for themselves and engage in some enjoyable activities in order to keep their mental health.
Hope from shared experiences
The model expands further after the sessions with gogos. After Friendship Bench clients have had their one-to-one sessions with a Community Health Worker, i.e. the gogos, they are invited to join Circle Kubatana Tose, which comprises peer-led groups that give clients ongoing support.
A circle is a safe space for people to come and share how they are coping with life or how they feel when they are not coping with life.
In the circles people get a chance to talk and share their experiences. The idea is that, when someone shares their problems and how they have overcome them – or are managing to cope with them, this serves as hope for a peer who may be going through a similar experience, but cannot see how to get through it.
Some don’t value mental health – they feel they don’t get enough in return.
In the circles, they also practice behavioural activation like crocheting, which is considered extremely important for a person’s recovery from any common mental health condition. Clients learn to crochet items from recycled plastic such as bags, baskets, or purses. They are then encouraged to sell the items created from their new skill as a form of income generation.
Some groups also practise permaculture, and the gogos share their knowledge with more communities; the clients learn to grow, pick and sell their own produce.
Goal to reach to whole country
The Friendship Bench is appreciated in the communities, but also faces certain challenges. The gogos are often affiliated with many help programmes; some might give people food, for example.
“People often expect to get something concrete out of participating a session with a gogo. We sometimes have people who expect something after they leave their phone number with us. Some don’t value mental health – they feel they don’t get enough in return,” Chawira says.
The organisation hopes to expand its presence throughout Zimbabwe. They want to reach out to more communities, but this requires resources.
But Chawira says the feedback has been positive – and you can see the gogos’ excitement as they gather together for lunch after the training.
It’s all about community support; the gogos get support from the organisation, and with that they support their own local communities.