What disease in the world today disables the most people? By many measures, it’s depression — and that holds nearly everywhere, whether you live in Zimbabwe or the United States. In poor countries, virtually no one gets treatment. But even rich countries run short. A survey in 2013 and 2014 found that about half a million residents of New York City had depression and that fewer than 40 percent of them got treatment.
The city is taking this problem seriously, mainly through the efforts of ThriveNYC, a program founded by Mayor Bill de Blasio’s wife, Chirlane McCray. (It has had mixed success — more on this later.) Perhaps the most curious effort involves giant orange Lego-style blocks on the sidewalk outside agencies called Neighborhood Health Action Centers in the Tremont section of the Bronx, East Harlem, and Brownsville in Brooklyn. These Friendship Benches show up at gatherings like street fairs as well.
The program involves people like Helen Skipper, known as Skip, and Steven Lopez. They sit on the benches and people talk to them about their problems. Ms. Skipper and Mr. Lopez aren’t therapists. Their most important credential is something you can’t teach — they’ve been there. “These are nontraditional safe spaces in plain view — no strings attached,” said Takeesha White, who is the acting assistant commissioner for the Bureau of Systems Partnership in the Center for Health Equity, which is part of the city’s health department. “You can work with someone who has a heart and understands and has been through the system.”
Mr. Lopez, 52, is a licensed counselor; his expertise is substance abuse treatment. Before that, it was substance abuse. His own route to sobriety started in 2009, when his wife was about to give birth to their first child and told him to choose. Then someone approached him on the street and offered him $20 to answer some questions for 10 minutes. Those questions turned out to be about what he wanted to do with his life. “I would love to be a drug counselor,” he told her. “If anything, I already have a master’s degree in drugs.”
Ms. Skipper, also 52, once wanted to be a doctor. Then crack took hold of her. For a while she was functional, working on Wall Street while getting high on weekends. Then weekends became all week. “There is not a facility for women, drug program or homeless shelter I have not been in,” Ms. Skipper said. “My kids were taken by family court while I was incarcerated.”
She’s been sober since 2007 and marvels at the normality of her life — she’s married, owns a car and has her own business selling Pride items. She and her wife go on Caribbean cruises.
Most of all, she’s a peer. Yes, that’s a career — a crucial one. “You can’t underestimate the value of people who have triumphed in this broken system,” Ms. White said.
The orange-block program is called the Friendship Bench, and it came to New York from Harare, Zimbabwe. When ideas spread around the globe, we’re used to seeing them go from north to south. That makes the reverse migration unusual. But Dr. Mary T. Bassett, New York’s commissioner of health and mental hygiene until a year ago, lived in Zimbabwe for 17 years, mainly working as an H.I.V. doctor. She knew Dr. Dixon Chibanda, the Friendship Bench’s founder, and his work. And Dr. Gary Belkin, who runs the city’s mental health department, had long studied ways to use nonprofessionals in mental health care.
The Friendship Bench has also spread because it’s a real breakthrough.
I got to see the Zimbabwe version in action. In Harare, the benches are the classic wood kind placed in the back or front yard of every health clinic. The city has a force of middle-aged and elderly community health workers known as Grannies. They sit in their brown uniforms and conduct problem-solving therapy with patients, right there on the bench.
Dr. Chibanda didn’t intend for it to be out in the yard, or to employ people who might or might not have finished high school. But the clinic where he started the program had no room inside and wouldn’t lend him its very busy nurses.
“That was a blessing in disguise,” he told me. It made the program cheap and easy to spread.
The Grannies received two weeks of training, to understand and diagnose depression and learn about problem-solving therapy. That involves guiding patients as they think through their problems and come up with possible solutions. Then the patients try them and report back.
Patients think of strategies like “I could ask my sister for some money” or “I could sit down with my husband and talk about his drinking.” Obvious solutions — but when you’re depressed, you think nothing can help, and it’s hard to come up with even these ideas.
And it works. A study published in the Journal of the American Medical Association found that Friendship Bench treatment effectively cured depression. It’s one of many studies showing that even lay people with little education can quickly learn to treat depression and anxiety.
Without the Friendship Bench, Zimbabweans would have virtually no mental health care, except for those who can afford the few private doctors. (When Dr. Chibanda finished his training, he was one of six psychiatrists in his class. The other five left to practice in wealthier countries, he said.)
But this is not just an African problem. Poor people suffer depression disproportionately. And while New York City has considerably more psychologists and psychiatrists than Zimbabwe does, not a lot of them accept Medicaid. There are other reasons people don’t get treatment: They don’t realize they’re depressed, they don’t know help is possible, they don’t trust the system or are daunted by its bureaucracy. Or maybe they can’t find counseling that is in their language or appropriate for their culture; they don’t know where to go, or their traditions demand they tough it out.
Ms. McCray has spoken about her and her parents’ depression. Mr. de Blasio’s father suffered from depression and alcoholism. The couple’s daughter, Chiara, also went through depression and drug and alcohol abuse as a teenager, and Ms. McCray has said it was hard to navigate the system to get her the help she needed.
But while depression is common, it’s not minor. Depression isn’t just sadness. It is a fog of negative thoughts (often inaccurate) that paralyze the sufferers so that they cannot respond to their problems, said Kari Frame, program director of Strong Minds, which spreads group therapy led by a lay facilitator for depressed women in Uganda and Zambia. Depressed people are more likely to get other diseases and less likely to take care of themselves so that they can be cured. It gets in the way of taking care of family, holding a job or staying in school. Curing depression is an anti-poverty measure.
I’m not going to tackle ThriveNYC as a whole — reports paint it as a well-intentioned and expensive mess. It is sprawling, working with 15 city agencies. Its finances are murky. Thrive has received a lot of criticism for its failure to track whether it actually helps patients.
But the program, however flawed, is responding to a real need. Other cities are following. London, for example, started Thrive LDN in 2017.
Bringing mental health care to hundreds of thousands of people means going to them. Every community has neighborhood organizations that residents love and use — our language, our culture, people like us. So ThriveNYC trains staff members of those groups to do basic mental health care — screening people, doing Granny-style counseling and connecting people to other resources.
The Friendship Bench started as part of Thrive, but the health department now runs it. Ms. Skipper supervises seven other peer workers. There are also interns, who come from the Fortune Society and the Osborne Association, groups that work with people in or recently out of the criminal justice system. A representative of the Friendship Bench program said that since its founding two years ago, the peers have talked to some 50,000 people and given light counseling and help in navigating city resources to about 9,000.
Each peer has a home base at one of the three permanent benches, but they also go out into the street and start conversations. On Friday a peer and two interns had brought benches to a street-play event in East Harlem set up by the local organization Concrete Safaris. They had signed up 24 people for a mental health first aid course. Peers also respond to crises, showing up after shootings, fires and other tragedies.
Mr. Lopez said he talks to 35 people a day on average. Peers collect demographic information to be able to evaluate the program but don’t ask people for their names. That’s necessary for trust, but it makes it hard to track whether people follow up.
In Zimbabwe, Grannies provide therapy, because no one else does. There are few services, mental health or otherwise, to which they can refer patients. (They can send a WhatsApp message to Dr. Chibanda or the program’s senior psychologist, Ruth Verhey, if a patient talks of suicide or is otherwise in crisis.)
In New York, Friendship Bench workers have many of the same kinds of problem-solving conversations. But they’re called coaching or counseling, not therapy. Their purpose is to open a door into the system — which many clients see as cold, bureaucratic and judgmental — for other services.
The peers help clients navigate the system — sometimes instantly. Mr. Lopez said that he has walked at least 50 people to various neighborhood services. He often goes in with them, helps with paperwork and makes introductions. Sometimes he stays for the whole meeting He has two clients whom he still takes to all of their therapy appointments.
“Nobody in New York City says, ‘Hi, how are you doing?’ and really wants to hear the answer,” Ms. Skipper said. “We do. And we are ready where we stand to help.”
Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.” To receive email alerts for Fixes columns, sign up here.
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