The Science of Connection

Published Mar 28, 2022, 4:01 AM

Dr. Dixon Chibanda, a psychiatrist in Zimbabwe, has been on a mission for years to help people gain access to mental healthcare in his community, where there's only one psychiatrist for every 1.5 million people. To bridge the gap and provide people with the help they need, Dixon turned to a rather unorthodox group for help: grandmothers.


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Pushkin. Just a heads up, we talk about suicide in this episode. Please take care while listening. In Zimbabwe, let alone the whole of Africa, you're looking at a ratio of one psychiatrist to about one and a half million people. That's doctor Dixon Chabanda, a psychiatrist in Zimbabwe. He knew people in his country desperately needed access to mental healthcare but weren't getting it, and even though Dixon felt daunted by the magnitude of the problem, he was determined to try and find a solution. My initial thoughts were to work with trained nurses and doctors at the hospital, but I was immediately told no, the nurses and the doctors are extremely busy. They have to deal with people who are living with HIV, they have to deal with people who are coming in with malaria, and all sorts of other things. They just don't have the time to do this mental health stuff. Since health professionals were fully tied up with other work, Dixon was forced to look elsewhere, and so in two thousand and five, he turned to a rather unorthodox group for help. On today's episode, how you can vastly improve access to mental healthcare when you put grandmothers on the case, I'm Maya Shunker, and this is a slight change of plans, a show about who we are and who we become in the face of a big change. Dixon and I started our conversation by talking about what drew him to the field of psychiatry. He had initially wanted to become a pediatrician, but then something happened in medical school that deeply affected him. A classmate of his, who outwardly seemed stable and cheerful, took his own life. This came as a total shock to Dixon, and it motivated him to reassess how he wanted to spend his time as a doctor. And then there were a couple of other things. You know, I grew up in a family where my parents they didn't really have a wonderful marriage, you know, if I could put it that way, And when my parents divorced, that really affected me psychologically emotionally. I think I must have had childhood depression for a very long time, and no one really knew, and I didn't know either, you know, So that all of these kind of things, and then going to high school and being bullied and then you know, feeling completely out of place, So quite a number of events which had an emotional or traumatic effect on me. I believe contributed to that final decision for me to get into mental health and psychiatry. The thinking was, you know, if I can understand more about mental health and mental illness, I'll be able to heal myself, you know, and and and that's actually what it's all about, you know, It's really about finding a way of making myself a better person. So you end up deciding to become a psychiatrist, and you end up having a patient named Erica whose experience inspires you to specifically work in the area of increasing access to mental healthcare. Do you mind sharing her story? Yeah, Erica. Erica was a twenty six year old patient of mine who I had been saying for a good close to three years. She was initially brought to the hospital where I worked as a psychiatrist with a history of major depression. And I spent quite a lot of time with Erica, and I've really got to know her, And I think that's one of the things with psychiatry, when you really connect with your clients, you get to know them on a very personal level, and you know everything about their lives, because I mean, that's what mental health is all about. You know, you talk to people, you listen to people's stories, and so, you know, over the years, Erica and I had built this very strong rapport. But Erica actually lived some three hundred kilometers from where I am, and she would come and see me once every month together with her mum, you know, for review. And she may had a lot of progress over the years. And you know, one evening, I get a call in the middle of the night from the hospital where I worked, and the er doctor, you know, informs me that Erica, you know, my patient, Erica has taken an overdose, but she will be fine. But you know they kind of think that after that she should really come over and probably get more psychiatric evaluation and attention. And you know, we agreed that that was what was going to happen, you know, as soon as she's released. But you know, Erica didn't come. When she was released from the ear they went back to the village where she lived with her mother and father, and I only got a call three weeks later from Erica's mother to tell me that Erica had had hanged herself. You know, when Erica's mother phoned me to tell me what had happened, and you know, my sort of instinctive knee jerk response was to say, to Erica's mother, why didn't you bring Erica to the hospital for the review that we had talked about, you know, after after she had taken that initial overdose. And it was her response really that that struck me, you know, because she said, you know, we wanted to come, but we couldn't because we didn't have a bus there to come to your hospital, and that was like ten dollars, and as a result, Erica couldn't really get the help that she needed. Yeah, and from what I understand, I mean, the fact Erica even had access to you already put her in a minority of people, right, just given the sheer number of psychiatrists in the area. Yeah, the ratio is actually quite appalling when you think about this statists, in terms of psychiatrists in Zimbabwe, let alone the whole of Africa, you're looking at a ratio of one psychiatrist to about one and a half million people. And I think, you know that that whole story about Erica got me really thinking about my role as a psychiatrist. You know, when you're trained as a psychiatrist. You you kind of see yourself working in a hospital. I mean, that's what psychiatrists do. You know, they work in hospitals. You know, we work in clinics. We deal with people. People come to us. And I started asking myself if this was really the right way of looking at my role as a psychiatrist in Africa, expecting people to come to me, And you know, I just realized that that just wasn't going to work. Erica's inability to access help and it mattered most had a profound impact on Dixon. He felt inspired to bridge this gap and access to mental healthcare, but wasn't sure how to do it. Then a moment of insight. Dixon was in West Africa at an academic conference being run by the World Health Organization when he caught wind of a local ceremony nearby. It was a spiritual gathering where a number of people had come together to try and heal those in the community who were suffering, and Dixon immediately took note of one particular aspect of this ceremony, the prominent role elderly women played in leading it. They were really powerful, but above all, they had this amazingly profound way of conveying empathy and connecting with their subjects. That was really what struck me, and that was when I kind of realized that there was something in having an older woman who has wisdom and experience reaching out to help a young mother who is struggling with postnatal depression, a young mother who is struggling with anxiety disorder, and just reaching out and establishing that connection that makes that person feel comfortable to share their story, to make them feel that sense of belonging that I am in a place where I'm being taken care of. That was really powerful. Dixon drew a lot of inspiration from observing the elderly women in that ceremony. The influence they had in the community because of their age, their wisdom, and their empathetic nature gave him an idea. Since there weren't enough mental health professionals in Zimbabwe to meet the needs of his community, Dixon thought one way to help could be to bring elderly women or grandmothers into the fold. If they could lend a compassionate ear to people who were struggling, that could give more people the support they needed. But when Dixon told his friends in the medical community about his idea. They did not share his enthusiasm. Well, the initial reaction was obviously negative. Everyone thought it just wouldn't work because therapy is designed to be delivered by trained therapists such as psychiatrists or clinical psychologists, and grandmothers with minimal education just did not have the capacity to do this kind of work. So friends in the field, colleagues and other senior colleagues as well who I looked up to, all kind of thought this wouldn't work, you know. But I guess at the back of my mind, I always had that vision of these elderly women, and also just looking at my own childhood as well. You know, I grew up in a family where the women were very strong, very powerful. Both my grandmothers, you know, were literate, were educated, and had a very strong contribution to the family and making decisions. So I guess that's another part of my history or my childhood that has influenced this work. Dixon did not have to wait long to test out his theory. Zimbabwe was reeling from a recent government crackdown which traumatized millions and left hundreds of thousands of people homeless. Against this backdrop, Dixon's medical supervisor implored him to double down on his existing efforts and try to find a solution to the growing mental health crisis. And at the time, I was the only psychiatrist actually working within the public health sector, you know. So my supervisor said, you need to go out there and you need to come up with something. You know, but there's no money. You know, you have to try and think of some innovative way of addressing the psychological trauma that this community is going through. And my initial thoughts were, you know, to work with the trained nurses and doctors at the hospital. But I was immediately told no, the nurses and the doctors are extremely busy. They have to deal with people who are living with HIV, they have to deal with people who are coming in with malaria and all sorts of other things. They just don't have the time to do this mental health stuff. But you could consider working with other, you know, non professionals, you know, And I thought, my goodness, this can't be done by non professionals, but just the thought then, you know, there are lots of community grandmothers here who have been involved in sort of outreach programs. How about I start with just fourteen grandmothers from this community and see what we can do. A part of me was also quite skeptical, but you know, when you think you onto some thing, you kind of keep going, you know. Yeah. I mean I can also imagine therapist and doctors reacting negatively because they're thinking, I have a real degree in this, you know, I'm actually trained, and now you're telling me that grandma's can do my job for me? Like, did you hear any of that kind of response? Yes, I had a lot of that kind of response. But you see, that's where I think, you know, the problem we have with today's education, where we see everything through the lengths of academia and academics, you know, particularly from the northern hemisphere, and we don't take time to look at the local indigenous knowledge and the wisdom that is inherent in every culture. I mean, one of the things that I really learned from the grandmothers is that every culture has the amazing ability to teach you a piece of profound wisdom. And this is something that I have really taken to heart from my interactions with a grandmother's, just appreciating more the local culture and the role that it can play in addressing not only mental health issues, but a wide range of issues that people are struggling with in communities or in society. Will be right back with a slight change of plans. Doctor Dixon Chibanda, a psychiatrist in Zimbabwe, had an idea for how to help more people in this country access mental health services, and it would come to be known as the Friendship Bench. Here's how it would work. Members of the community with mental health needs would be paired with a local grandmother. They then plan to meet up at a bench outdoors and work through problems the person was facing. Dixon took his idea to some grandmothers in his community in order to get their feedback. I was given fourteen grandmothers who were not very excited about working with me initially because you tell me more about that. Well, you know, when I approached them, I had my psychiatrist's hat, and over time, over the years, I've realized that when you really want to engage with communities, you need to take off your professional hat. If you really want to heal people who are traumatized in this part of the world, you need to rely on the local language, the local idioms of distress, and just use the language that resonates with communities because when you use your own language, you instantly remove stigma, because stigma is one of the biggest problems that we face in mental health. And in this part of the world, stigma is brought about because we're trying to adopt terms that I used in the Western world. You know, if you talk about depression in my country, people think you've lost it yourself. That people don't believe there's depression. People think that depression is something that just doesn't happen to people in this part of the world. But if you use the terms which which resonates with the local folks, like in our culture, for instance, the equivalent for depression is a word called kofungi sisa, which literally means thinking too much. When you break down the symptoms of thinking too much in the local language, it's exactly the same as depression. So, you know, I learned from the grandmothers that the words that we use and the terms that we use to describe people's emotional experiences can make or break people. Fascinating So, so you said, the grandmothers were not excited initially about the prospect of working with you, but you learn to adopt the language of the locals, right, and to make sure that you're speaking in their terms. Was that effective in getting them onto your side and motivating those fourteen initial grandmothers to want to partner with you. I remember Grandmother Jack, the very first grandmother who I interacted with and spoke to about the Friendship Bench and the idea that I had. She was very apprehensive initially and dismissive when I first approached her because I was I was using lingo from the DSAM five, you know, the Diagnostic Statistical Manual, which is kind of the psychiatrist's handbook or bible, you know, and I was using terms from that book. And she's looking at me like, and you think that kind of stuff is going to fly in this community, you know, totally interesting, you know, And I remember distinctly, you know, she said, if you really want to make a difference in this community, you have to put down your book and don't come here acting like a doctor. She knows the community inside out. And I persisted, you know, every week, you know, I'll go to the to the clinic, you know, meet the grandmother's and you know, Grandmother Jack would be looking at me, you know, very skeptical, and and and and gradually, you know, she warmed up to me, you know, and gradually, you know, they're bought into the whole idea or therapy on a bench. Yeah. You know, you said that the grandmothers eventually warmed up to you. But it seems like a key feature of that is the fact that you maintained an open mind throughout right you were you were viewing this as a dialogue between you and grandmothers right at the two way street, in which both sides were contributing to the conversation. And I think that's so that's such an important lesson for people who are trying to bring new and innovative approaches to their communities. You know. An example of this is that initially you would plan to call the bench the mental health bench, right yeah, and no one was coming when it was called the mental health bench. And then the grandma's you know, came to you. I imagine Grandma Jack was among them and said, look, Dixon, you need to change the name to friendship bench. No one is going to come to the mental health bench. Yeah. Yeah, And that's a good example of me having my psychiatrists hat on, you know, like, hey, this is we're providing mental health services. Yes, so this is the Mental Health Bench. And it just didn't occur to me that a name could make or break a program, But I've learned now. You know, the language is very important, the language that you used to navigate through the therapy, through the session, that's critical because that's what people identify with. So yeah, indeed, everything is in a name. I guess I'd love to dive a bit deeper into the features of Friendship Bench, and there's this very strong storytelling component involved. But what's trucking me about the program is that both sides are encouraged to share their stories. And I find this fascinating because in the clinical world, providers are often discouraged from sharing personal stories. Right. Yeah, but you've identified that there are huge therapeutic benefits to having people bond in this way. So can you share a bit more about that? Sure? I think before I share one of the things, I'd like to also just mention that through my interaction with the grandmothers over the years, my own approach as a psychiatrist has changed significantly. I am more comfortable sharing my own story with clients who come to me for help and I find that extremely powerful because you really connect at a human level. You know, when we're trained as psychiatrists, we're trained to keep this distance, don't really open up, don't show your vulnerabilities, because as a therapist you're supposed to be strong. But actually there's a lot more strength in showing your vulnerabilities. There's a lot more strength that comes from telling your own story, including the negative things, because then you really connect. Because one of the things I've learned from Friendship Bench is the therapy actually starts when you connect with a person. The different steps that you take in the process of reaching out to people are important, but if you do not have that connection that ra poor you may lose everything else. So if you ask me what I consider to be the most critical feature of the work we do, it's that connection. Being able to get two people to connect in a way that is empathic. And that's the first part, you know, which the Grandmother's called or opening up the mind, because without opening up the mind, you don't get to the root of the problem. The other key component that we emphasize is the Grandmother's ability to summarize. So if you're listening to a story, you know this is what I normally would say to the grandmothers if if you're listening to a story, how does the person that is telling the story know that you really were listening? And the simplest way is a summary. You know, a good summary of what you've heard shows how well you were immersed in this story. And you can see from the grandmothers who are brilliant at summarizing, they are also the best grandmothers when it comes to immersing themselves into a story and also showing that empathy and that ability to make people feel respected and understood you. So those are the two key components. Another component of the friendship bench is a diagnostic screening tool. The grandmothers have everyone who comes to the bench fill out a questionnaire so they can get a better sense of what kinds of symptoms the person is experiencing and their degree of severity. If someone presents with severe symptoms, the grandmother refers them right away to a trained medical professional, but if someone presents with more mild to modern symptoms, the friendship bench is for them. Grandmothers are trained in a form of cognitive behavioral therapy called problem solving therapy, which focuses on identifying concrete problems like unemployment rather than the symptoms of that problem, like anxiety. Grandmothers then work with a person to brainstorm specific steps they can take to solve the problem, and according to research, this focus on resolving specific problems can give people a greater sense of agency over their lives. A classical sort of presentation on the bench is, you know, a young client presenting with numerous problems. I'm HIV positive, I'm unemployed, I mean an abusive relationship, I have a child who is not able to go to school because I don't have money to pay for school fees. I'm struggling to feed my family. So they present with numerous problems, you know. And one of the things that has really characterized the therapy component is the ability to help these clients who come to the bench after sharing these stories, the ability of the grandmothers to help them select one problem to focus on. And that seems that sounds very simple, but actually, when you're immersed in all these problems, every single one of those problems is a big problem for you. So because the grandmothers live in these communities, the actual treatment is often not only on the bench, but it also occurs in the community. So you can get a grandmother meeting a client, for instance, at church. So I'll see you this Sunday at church and you and I can pray together. I will see you at the market and we can do this together. So you're slowly introducing a very practice called kind of behavior activation to help someone who is depressed and unmotivated and isolating themselves at home because they feel they are in this miserable situation. But because the grandmother has come up with this set of activities that they then carry out together, you slowly begin to see this person transforming, you know. So that's one sort of example of how the grandmothers will deal with situations of depression. Often people think the work we do is just on the bench. The bench, the friendship bench, or the bench. The physical bench is just an entry point. There's a lot more that happens outside of the bench. We encourage everyone who sat on the bench with the grandmother is to join a support group in the community. And through the support groups that you get peer support with individuals who've all gone through the friendship bench, share their own experiences and collectively problems solved around challenges that they are facing within the community. I'd love if you could talk about the efficacy of the program, because you actually ran a randomized control trial, which is considered the gold standard of evaluation, and found some extremely exciting results. Yeah. So we have over fifty peer reviewed publications, you know, scientific publications about the Friendship Bench, But I guess the most seminal publication would be our cluster randomized controlled trial, which is published in the Journal of the American Medical Association, which in a nutshell, shows that six months after receiving therapy from a trained community grandmother on a bench in Zimbabwe, people were steal symptom free. The grandmother where in essentially much better than enhanced usual care. And enhanced usual care was a trained mental health nurse, clinical psychologists or psychiatrists, you know. And I think the reason why the grandmothers tend to be better is because they are rooted in their communities. The grandmothers are the custodians of local culture and wisdom, you know. And it's positively changing the lives of grandmothers as well. Yeah. One of our most recent publication actually took a random sample of grandmothers who are working on Friendship Bench and compared them with a similar random sample of grandmothers with similar sociodemographic characteristics, and we found that the grandmothers who work on Friendship Bench were a lot more resilient, They had lower rates of common mental disorders and post traumatic stress disorder. And when we dug deeper, we actually found that this work gave the grandmothers a profound sense of purpose and a sense of belonging. And this is why they do this work. It's a win win. Actually, they are not only reaching out and helping people, but it's helping them too. So one thing that's been so exciting about the program is that the Friendship Bench is scaling to places all over the world. What are your future dreams for this program, like if you could wave a magic wand what is the presence of the friendship Bench like in communities all over the world. The vision of Friendship Bench is to actually have a friendship bench within walking distance everywhere. It sounds grandious, very ambitious, but it's something that I am working towards because in every culture, people thrive when they connect with each other. And the Friendship Bench is not just an intervention that addresses mental health issues. It's really an intervention that connects people, and I think that's where the real power of this comes from. And when you connect people, particularly using grandmothers or the elderly, you have this profound sense of belonging and it creates a sense of purpose, particularly for the grandmothers and the you know so. So I think that's that's what I would like to see, you know, in the next coming years. And fortunately we are, you know, we are gaining traction, and I just want to make it possible for every person out there who needs to connect, who feels they need to talk, to be able to talk to someone who is empathic, someone who's able to respect them and to understand them. Hey, thanks for listening. Join me next week when we hear from Quinn Lewis, a college student who's mourning the tragic death of her younger sister, Dixie and the future relationship she had envisioned for them. We would always bring up how different we were from each other, were such different people, and I felt in the last few years that was changing and it felt like the future felt intertwined, is how I would put it. It felt like we were going somewhere together. A slight change of plans is created, written in exact get produced by me Maya Shunker. The Slight Change family includes Tyler Greene our senior producer, Jen Guerra our senior editor, Then Talliday our sound engineer, Emily Rosteck our producer, and Neil LaBelle our executive producer. Louise Scara wrote our theme song and Ginger Smith helped arrange the vocals. A Slight Change of Plans is a production of Pushkin Industries, so big thanks to everyone there, including Malcolm Gladwell, Jacob Weisberg, Lee, tamlat and Heather Fain and of course a very special thanks to Jimmy Lee. You can follow A Slight Change of Plans on Instagram at doctor Maya Schunker, See you next week. Is there any chance for grandfathers? When we first started, we did involve some grandfathers. The challenge with grandfathers is they just don't have the same ability as grandmothers when it comes to creating space and letting people tell their stories. Grandfathers tend to be prescriptive. They tend to tell you what you need to do. You go and talk to this person, and go and do this. You know. So there's some man's plaining going on, Yes, quite a lot of it

A Slight Change of Plans

You can follow the show at @DrMayaShankar on Instagram. Apple Podcasts’ Best Show of the Year 2021. 
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