Friendship Bench—A Model for Accessible Mental Health Careby Dominic Velasco, MD, MBA | August 13, 2018
In 2017, Mental Health America reported that one in five adults with mental illness say that they are not receiving the mental health care that they need. (Mental Health America, 2017) The reasons for this are the following:
- (1) they do not have insurance for it
- (2) they do not have enough money to pay for the service
- (3) mental health care providers are lacking
There is one mental health care provider for every 529 individuals in the US. This gap widens significantly for specialized mental health care. Only 20% of children with mental health problems receive some form of mental health services. The reason is that there are only about 8000 child and adolescent psychiatrists practicing in the US. In San Francisco alone, the Center for Disease Controls and Prevention (CDC) reports that there are about 32 child psychiatrists and 88 child psychologists per 10,000 children ages 0 to 17 years old.
There is a need for re-imagining the delivery of mental health care. One such method is known as the Friendship Bench Intervention (see video). The friendship bench has been undergoing development for more than 20 years in Harare, Zimbabwe where the Harare City Health Department in collaboration with the University of Zimbabwe Medical School sought to solve a major cause of disability from non-communicable diseases in the region, mostly common mental disorders such as depression and suicidal ideation.
The Friendship Bench is a task-shifted brief intervention and problem-solving therapy for common mental disorders which is provided by female lay health workers trained in specific aspects of cognitive behavioral therapy, particularly in problem-solving therapy and behavior scheduling.
In short, the Friendship Bench mitigates common mental disorders such as depression by utilizing female lay health workers who are trained and supervised by clinical psychologists and psychiatrists to perform problem-solving therapy in a primary care setting.
The problem-solving approach starts with the patient identifying the cause of his mental illness. For example, unemployment. Interestingly, this approach deviates from the conventional where experts aim at diagnosing the patient from the symptoms that they present. Problem-solving therapy aims to provide a positive orientation of the patient towards resolving these identified problems. This makes them realize that they can have control in overcoming their mental illness.
The lay workers follow a script and conduct 6 sessions lasting from 30 to 45 minutes for each patient. The first session involves three components: (1) Opening the Mind or kuvhura pfungwa, (2) Uplifting or kusimudzira, and (3) Strengthening or kusimbisa. The first session aims to let the patient open their mind and identify their problems. They would then be allowed to choose only one to work on. The lay worker and the patient will then identify how to solve this problem realistically and formulate an action plan. This is an iterative process where the subsequent sessions will develop based on the first session.
Common mental health disorders that the Friendship Bench aims to treat are the following: depression, anxiety, panic disorder, post-traumatic stress disorder, cognitive disorders, and substance abuse.
Hiring and training lay workers from the community can significantly increase the mental health workforce. The requirement for the adult female trainees in this program is an educational background with at least 8 years of formal schooling (secondary schooling may suffice). The average age of the trainees is 58-years old. The training can be easily implemented, and it is cost-efficient at only $200 per health worker.
Figure 1. An Example of a Theory of Change Framework Output. LHW = Lay Health Workers
Community engagement is a key process in the development of the Friendship Bench. The goal is to bring community members, experts, researchers, and other key stakeholders together and become equal partners in the program. They engage in a workshop to develop a theory-driven framework known as the Theory of Change. Members hypothesize the best treatment initiative plan for the community’s patients and form a theory of “how and why an initiative works?”. Variables are identified and constantly measured for every cause and effect pathway. This illustrates proof that an initiative has a positive or negative impact. The theories are continuously measured, challenged, and changed until the desired impact is formulated (see Figure 1).
The success of the program is heavily reliant on the training method, the translation of the manual to the local language, and the integration of the program with the culture of the community. Lay workers must also learn how to translate and utilize tools used in common mental disorders such as the 20 item Self-Reporting Questionnaire (SRQ-20), General Health Questionnaire (GHQ-12), Hospital Anxiety and Depression Scale (HADS-D), and Patient Health Questionnaire – 9 Depression Test (PHQ-9). These are the basic metrics used to determine if the therapies are working.
Adding to the workforce, competent lay mental health workers in the primary care setting can offset the gap in mental healthcare delivery in communities. Its success in first-world countries is more likely because its growth can be sustained by leveraging readily accessible financial resources allocated each year by public health organizations. Its robust infrastructure, particularly in primary care clinics and information technology such as telehealth services, can boost the Friendship Bench programs. A limitation of the Friendship Bench is that it is designed to treat adult common mental disorders. To emulate this program so that it can suit the need for pediatric mental health disorders is of importance.
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