Where there is no Psychiatrist, Community Health Workers have been proven to be effective in providing high quality stepped up care to improve mental health outcomes in populations with high exposure to HIV and despairing social stressors such as domestic violence, substance misuse, poverty and complex cultural factors that add to the burden of disease.
I love working in grassroots health programs. Over the years I have been privileged to work with Tarisai Bere, a leading Psychologist on the Friendship Bench project in Zimbabwe. There is an intimacy that comes with working in partnerships between the Diaspora and home based programs, over time I have grown to cherish the warm relationships that we have developed with the Community Health Workers who are the real champions of the Friendship Bench. They embody their roles with a great sense of ownership and responsibility to their local communities. I love that they break into a song every so often, and address their own mental health challenges through community cohesion. Culture is pivotal in identifying and understanding complex social changes and these Community Health Workers understand this all too well.
We have achieved remarkable milestones in improving mental health in Zimbabwe, indeed high income countries have much to learn from the Zimbabwean model of stepped up care. Psychologist Tarisai Bere is a driving force in innovation and integration of mental health development in Zimbabwe. Tarisai takes time from her busy schedule to talk to Dorcas Gwata, Director of Tribal Sands:
Tarisai, you are one of the leading Psychologists working in Zimbabwe, can you tell us how it all started?
There are a few gurus before me in this field whose footsteps I’m following in.
The Friendship Bench started in 2006 in Mbare (which is one of the oldest high density areas in Harare) when a group of stakeholders came together to look into mental health issues in Zimbabwe particularly in the Primary Health Care clinics. It was a combination of Doctors from the UK (Dr Abas and Dr Vikram Patel), Doctors from Zimbabwe led by Dr Chibanda, Psychologists and researchers from the University of Zimbabwe and other stakeholders. They came up with the tool we now use to screen common mental disorders, the Shona Symptoms Questionnaire 14. A few Health Promoters (HPs) from Mbare were trained to screen and provide the intervention for Kufungisisa -Common Mental Disorders. In 2014- 2015 a Randomised Control Trial was carried out in 24 clinics and the results showed that the HPs could deliver the intervention successfully and outcomes of the CMDs improved.
The Friendship Bench (FB) project has grown from a pilot project in Mbare to a large scale up, how did you get involved with it?
I officially joined the FB during the adaptation of the Problem Solving Therapy as part of the clinical team in 2013. In the year 2014 to 2015, I assisted with the coordination of the Randomised Control Trial. This year I’ve been mainly involved with the training of the intervention to the HPs, checking its fidelity and the implementation of the scale up to the about 60 clinics in Zimbabwe.. I also provide clinical supervision and this is more of a referral point for severe and suicidal cases. We have trained close to 300 HPs in Harare, Gweru and Chitungwiza. It’s been an amazing journey.
What are you proudest moments on the Friendship Bench Project?
I have plenty but if I were to pick one I would say the journey I’ve had with the Community Health Workers during and after training. I’ve seen them grow from strength to strength, absorbing the knowledge imparted on them like superstars. To be honest I didn’t think they would be able to understand a psychological intervention with their educational background but they all surprised me. It’s been such a blessing to work with them, and I think there is nothing more gratifying than hearing your elders pray for you in gratitude thanking the Lord for you as teacher. Indeed a proud moment.
The FB model has helped to bring mental health into the open, what lessons do you think high income countries can learn from low income countries like Zimbabwe?
A problem shared is a problem half solved Dorcas, this is the greatest strength of this model. The intervention allows you to talk about your issues. In speaking out and emptying out your problems someone (in individual sessions) is there to guide you and hold your hand then a whole village in Circle Kubatana Tose (group therapy) is there to strengthen you. The richness of our culture of Ubuntu,(a person is a person through other people) spirituality and togetherness is what makes this model work best. You are allowed to open your mind to finding solutions in a loving and safe environment-Humbly under a tree on a bench. People are not afraid of speaking out anymore, there is no fear of judgement and a lot of misconceptions about mental illnesses are being corrected. Our grandmothers (the CHWs), do it with so much love and passion.
The ladies report that the problem solving tool and the Circle Kubatana Tose (CKT) has helped them greatly in improving their own health, and are you surprised by this outcome and what lessons other health care systems can adapt in improving the health of the health care workers.
I’m not surprised at all. Circle Kubatana Tose is the group therapy of the intervention where the ladies meet to share their own problems be it personal or work related. They help each other through different challenges. It’s amazing how sometimes when they are not sure of how to console someone they will just sing, pray and dance until they are all in good spirits. It’s truly amazing therapy. It’s important to keep in mind that these ladies have issues of their own and need to be taken care of. CKT gives them and their supervisors a chance for self care before they go out and do their work. They then teach CKT to their clients after 3 individual sessions, which is another platform for them to engage in group therapy.
You were one of the leading Psychologists on the Tendai Project which was based in Parirenyatwa Hospital; can you tell us more about the project and its findings?
The ‘Tendai’ project was an initiative to treat depression and improve adherence in People living with HIV. For ‘Tendai’ we used Problem Solving Therapy and Lifesteps which is an adherence intervention for Anti Retroviral Therapy (ART) adherence. We culturally adapted Lifesteps and named it Nzira Itsva which can be loosely translated to New Direction or New Map in English. We did a pilot trial to see if reducing depression and providing a psychological adherence intervention would improve outcomes of taking the ART. The preliminary results were quite positive so we are now working on doing a Randomised Control Trial in the Primary Health Care clinics. We have published on the work done so far in two journals, the Journal of Tropical Medicines and the Journal of Health Psychology and we have two more publications we are working on.
Rates of Gender Based Violence (GBV) in Sub-Sahara are particularly concerning, Zimbabwe included, what more can we do to provide better mental health care for those affected and traumatised by gender violence.
I think people suffer a lot in silence both men and women. We need to talk about Gender Based Violence a lot more and break the silence. A lot of people who experience Gender Based Violence suffer from different types of mental conditions but do not know where to go for help. We need to create a lot more awareness.
How can the Zimbabwean Diaspora add value in scaling up mental health training in Zimbabwe?
By coming home more often, to understand what’s happening, and help put Zimbabwe on the Global Mental Health map. We might not be able to turn around mental health care in one year but as the saying goes a journey of a thousand miles, begins with one step. Do what you can, if it’s volunteering for two weeks, we need more hands, if its research that will bring in help and money then do it, and it doesn’t have to be huge donations but maybe just your time and passion.
You lived in London briefly and moved back to Zimbabwe, have you ever looked back on that decision, and what keeps you anchored to Zimbabwe?
I lived in London for almost two years and I won’t lie I do miss London at times but coming back home was the best decision I ever made. Being in London and celebrating different cultures made me realise that there was a lot I didn’t know about myself, my heritage and my culture. I came back home to find myself. I began to learn more about my heritage, born of the Chief Tangwena clan I fell in love with my history. In learning more, I came face to face with some beliefs and practices that were unhelpful too. This was at a time when a lot of people were dying of HIV and soon after the introduction of more ART in Zimbabwe. What was striking for me was the misconceptions and the negative attitudes that surrounded the condition and especially the mental disorders associated with it. HIV induced psychosis, depression, anxiety, PTSD and other mental disorders were mistaken for evil demons and curses. I realized that a lot of people were dying because of lack of information. I went back to college to study Psychology; I wanted to be in a position to help more. That was the beginning of my journey in mental health. It’s true what they say that when you find your life’s purpose, everything falls into place. After my graduation I joined the 3 year in house training for clinical psychology at Parirenytwa Hospital where I was able to meet and provide therapy to more people with different mental health disorders and living with HIV. The Tendai project came to me like an answer to a prayer because my passion has always been to integrate Mental Health and HIV care. Tendai gave me a chance to do that. Through Tendai I was then introduced to the Friendship bench where I now help people at a wider range. I also help people with other chronic illnesses and not just HIV. I go to work to do my hobby, my career is my passion this is what keeps me anchored in Zimbabwe, that, my amazing husband and children and the wonderful weather of course. Precious sun!!!
Who are your mentors and why do they stand out?
My parents really, my dad was a community leader for as long as I can remember, liberation fighter, he helped rebuild our community in the 80s. I saw him single handily working very hard to make sure that our community had more schools, more houses, better roads, clinics and other infrastructures. He is a building constructor by profession but a lot of the things he did, he did for others. He was always very passionate about our community’s welfare.
My mum was always the unsung hero, and the passion I have to help people comes from her. After the liberation war she volunteered to teach old women to read and write, I think it was called adult literacy then. She taught the young women to be entrepreneurs through sewing school uniforms, baking cakes and knitting woollies and a lot of them started their own businesses which are still standing up to now. What was outstanding for me though was the campaign she started in our community to encourage parents to educate the girl child. Back then people didn’t believe in sending the girl child to school and she went from one house to the other encouraging fathers to send their girls to school, so yes when I grow up I want to be my mum lol.
Career wise my mentor is without a single doubt Dr Melanie Abas. I met her in 2013 and these past 3 years have been the climax of my career. She has pushed me to do things I didn’t think I was capable of. She has believed in me so many times when I doubted myself. In the past three years she has encouraged me to publish in a peer reviewed scientific journal, and has pushed me to speak on international platforms. Highlight of my career would be when I shared the podium with her as key note speaker at the Malawi, Scotland, Mental Health Conference held annually in Malawi. I think she knows I suffer from stage fright so every time I am about to speak and she is there she whispers “you are going to be great, you’re a natural” I am forever grateful for her passion in selflessly building and mentoring other people.
Back home, I have learnt a lot from Dr Chibanda who is also a fantastic mentor. He also pushed me to do a lot and has always been very supportive. He has taught me a lot about the local and global mental health. He has over the years encouraged me to take risks and better myself academically and professionally.
‘I was thinking too much': experiences of HIV-positive adults with common mental disorders and poor adherence to antiretroviral therapy in Zimbabwe
Tarisai, thank you for talking to me on Tribal Sands, please continue on with this brilliant grassroots work.
Thank you to Dr Dixon Chibanda and Dr Melanie Abas and all the wonderful staff at the Friendship Bench Project as well as those who worked at the Tendai Project in Parirenyatwa Hospital in Harare, Zimbabwe. Thanks to my colleagues at Zimbabwe Health Training Support Charity.
Director Tribal Sands
Trustee for ZHTS