[Invited Submission - Special Issue]
The More We Are Together, The Happier We Are: Peer Music in Mental Health Treatment in Zimbabwe
By Jeffrey Robert Angell & Ruth Verhey
Abstract
Ruth Verhey is a clinical psychologist involved in developing and running the Friendship Bench, a comprehensive, group based mental healthcare initiative in Harare, Zimbabwe. In 2013, she invited Jeffrey Angell, a music therapist from New York City, to facilitate one of the weekly Zeebag support groups at Harare Hospital. The Zeebag group is comprised of eight women who suffer from depression. The essay provides Jeffrey's first person accounts of this experience, as well as describing the music, music process, and how these intergrate into the peer empowerment model of the Frienship Bench.
Keywords: Zimbabwe, Africa
I had yet to unlatch my guitar case when the group of 8 women erupted in song. I was startled: their voices confidently singing in harmony, upbeat hands clapping in unison, feet shuffling, bodies swaying, eyes beaming and smiles abounding. No voice in the group was silent. The rhythm was infectious. A visiting music therapist, I watched and listened, overcome. When the music subsided, I joked, “You don’t need me here!” We laughed. “Tell me, what were you singing?” “A welcome song, thanking you for being with us.”(Jeffrey Robert Angell's first person narrative)
The Zeebag women are a part of The Friendship Bench Project, a mental health support group in Harare, Zimbabwe addressing depression, or “kufungisisa” in Shona, the local language. Kufungisisa translates to thinking too much as there is no direct translation for depression in Shona. Ruth, a clinical psychologist involved in developing and running the Friendship Bench, invited Jeffrey, a music therapist from New York City, to facilitate one of the weekly Zeebag support groups at Harare Hospital. Jeffrey visited Zimbabwe for two weeks in October 2013 where he lectured on music therapy to students and faculty at the University of Zimbabwe, conducted clinical sessions at clinics throughout Harare, and was the guest speaker at a local therapist supervision group. He was meeting the women for the first time.
After the women finished their welcome song, I spoke up, “I’d also like to share a welcome song. We go around the circle and sing each other’s name.” I unlatched my guitar and sang the coda of “Hello, Goodbye,” a song by the British rock group, the Beatles. Moving in a circle, we sang every group member’s name, including clinicians. As the last chord rang out, one woman spoke up, “Wait! We have another welcome song.” My anxiety that I would struggle to find common musical ground 8,000 miles away from home in Zimbabwe was relieved. Together we sang, “The more we are together the happier we are.” (Jeffrey Robert Angell's first person narrative)
Zimbabwe, like many developing countries, faces a mental health treatment gap. In 2010, mental, neurological and substance use disorders made up 14% of the global disease burden, with almost three quarters of this burden occurring in low and middle income countries (World Health Organization). In the developing world, it is estimated that there is a 75% treatment gap with a majority of people having no access to psychiatric and psychological treatment (2010). The Friendship Bench helps close this gap by empowering lay community health care workers to deliver a six week cognitive behavioral therapy (CBT) intervention, teaching clients to take ownership of their problems and to learn to find solutions themselves, thus alleviating the burden of employing specialized health professionals. The Friendship Bench model fits well with current World Health Organization global mental health goals in being a “high need, low cost” model of “informal community care” and “self care,” by delivering an evidenced based intervention (CBT), and through incorporating music it is also delivering culturally relevant care (Saxena, 2014).
Engaging in music is a therapeutic process for the Zeebag women of the Friendship Bench; smiles, laughing, and dancing belied depression that sunny Monday morning. Paul Brickhill, the late founder of Harare’s Book Café, a cultural hub and longstanding live music venue, stated, "Music is therapy everywhere in Zimbabwe (and the whole of Africa), but no one ever calls it that. It just 'is'" (P. Brickhill, personal communication, September 16, 2013).
In the hour spent together, Jeffrey and the Zeebag women took turns introducing songs and activities. Common ground was found in singing a traditional British children’s folk song, “The More We Get Together,” and Christian hymns: “Amazing Grace” and “What A Mighty God We Serve.” In these songs, everyone in the session was able to sing together. Recent articles and studies reveal that when people sing together stress is relieved, anxiety is lessened, and endorphins are boosted (Horn, 2013). Moreover, “singing one part in a part song is an elaborate accommodation of individuality to a collective will” (Burrows, 1980, p. 189). When multiple individuals sing the same tone, the effect that is created is called the chorus effect. The tone created is fundamentally different than if one singer’s voice was amplified to the degree that the decibel level achieved when multiple singers sing together (Backus, 1977). For these women, who may be feeling stigmatized, alone, and suffering from depression, this merging of self with others in music has an empowering effect.
In addition to singing, the Zeebag women of the Friendship Bench have access to several traditional Zimbabwean wooden drums. The drums are tall, slender, and have animal skin heads. The women also have access to small tambourines and shakers with colorful streamers. The women primarily use the drums and percussion to accompany the singing of religious songs.
Though unfamiliar with Shona songs led by the Zeebag women, the English speaking clinicians were able to engage in the music by playing to the pulse of the rhythm, either on the body of a guitar, on one of the animal skin drums, or by clapping. In at least one song, Jeffrey was able to find the key and accompany the melody with simple guitar chords. Following each Shona song, the women offered a lyric translation when asked, providing an opportunity for the women to explain the meaning of the song and for the group to reflect on it.
In addition to the outward smiles, laughter, and physical engagement (dancing), the songs introduced by the women included themes of community (“the more we are together”), happiness (“the happier we are”), thanksgiving (“a welcome song, thanking you for being with us”), and praise (What A Mighty God We Serve). Indeed, the content of the songs chosen by the women responded to the issues they were addressing: stigmatization and depression, as well identifying the available resources of community and faith. Whether consciously or otherwise, these women were using music to address their mental health challenges.
After sharing a number of songs, Jeffrey introduced an instrumental music therapy activity whereby participants took turns playing a solo on a single drum placed in the center of the group circle. He asked if one of the of the group members would start a rhythm and explained that once established, the rest would join by playing one of the available drums, tambourines and homemade shakers (there was enough for everyone in the group). One woman quickly volunteered. She had established herself as a musical leader in the session. She played the tallest drum. She helped initiate songs that other group members suggested, and sang a louder, lead part. The other women and clinicians accepted her in this role, uncontested. After she established the rhythm and others had joined, Jeffrey modeled the activity by going to the center of the circle and playing a short drum solo. Other group members followed--some enthusiastically, others with reluctance. Peers encouraged reluctant members and eventually everyone took a solo—some short, others long, some loud, others quiet. In doing so, as with the welcome songs, each unique group member was individually acknowledged and validated.
As the music was being created, other clients and clinicians from the hospital grounds found their way to the session, drawn in by the music, eager to observe and in some cases, engage. As the room where the session was taking place was open—having only three walls and a roof, the music carried into the open air and curious seekers were able to congregate and observe what was happening.
A crucial component of the Friendship Bench is peer empowerment. Normally, the Zeebag peer support group includes the sharing of personal experiences, storytelling, and praying in addition to singing, drumming, and dancing. This group is comprised of eight women who have been meeting regularly for the past five years. The women are all gifted crafters and in conjunction with the Friendship Bench research team have developed a beautiful range of high quality bags made from recycled plastic—mostly discarded plastic bags. The craftwork engages the women in an additional process of product design and development, broadening the scope of their support group to a business cooperative whereby they generate financial support, engaging national and international customers.
The Zeebag women are also trained as peer support leaders for newly formed support groups outside of their own, creating other safe forums of support for other women united by a common experience of depression or anxiety. The participants of these support groups are also taught the Zeebag group’s craftwork skills to make their own handbags from recycled plastic, a way to generate an income.
The peer empowerment model of the Friendship Bench was reflected in the musical process that played out that Monday morning in October 2013: (1) The women introduced and led songs without prompting, drawing on their own cultural heritage and strengths, (2) the lyrical content of the songs chosen was directly related to the mental health challenges they were addressing, (3) leadership emerged from amongst the peers to help initiate and facilitate musical engagement, (4) peers provided encouragement to one another to engage in the music therapy activity presented, and (5) engagement of the Zeebag group in this musical process drew members of the outside community to the session, expanding its reach.
In 2006, the Friendship Bench was initially offered in one high-density suburb of Zimbabwe’s capital, Harare. More recently, it has been scaled up to additional clinics with the hope that it will soon be part of Harare’s ongoing health program. During the session described above, the therapeutic impact of music on emotional well-being was reinforced and the Zeebag group has been using it in peer support groups ever since. Though the group had been singing at times prior, the use of drums and the intentional therapeutic use of music increased significantly after Jeffrey's visit. The group finds music particularly helpful in navigating difficult times when group members share stories of sickness, death, poverty and loss. Conversely, music is also used to express happiness when an opportunity to sell Zeebags is successful and money is received for their hard work, or when a music therapist visits from America.
Future Inquiry
In areas with limited feasibility of employing licensed music therapists but with rich communal music traditions, therapeutic benefits can still be reaped from peer-led music groups that are supervised by clinicians or lay health workers.
Reflection
Engaging in music with the women of the Friendship Bench proved to be an opportunity to witness how another culture engages in music therapeutically. The session revealed how deeply engaged they are. It was also an opportunity to demonstrate how music can be integrated into a therapeutic context in a healthcare setting. Moreover, for Jeffrey, it resulted in an experience of joy of being welcomed into a foreign community. Prior to the session, Jeffrey had been concerned that cultural barriers might prevent the development of an initial therapeutic relationship, make finding common musical ground difficult, and thus thwart a meaningful session. When the women broken into their welcome song, these concerns were allayed. Perhaps in this Zimbabwean community music is a deeply engrained cultural practice and frequently exercised in “ordinary contexts, [where] little or no importance is therefore attached” (Aluede, 2006). However, as experienced that Monday morning, music’s effects are nothing short of extraordinary.
Acknowledgements
Dedicated to Paul Brickhill, musician and founder of The Book Café in Harare, Zimbabwe, a lasting champion of music, culture, and human rights. Jeffrey thanks his wife, Rachel, whose support, assistance, and encouragement led to his rich experiences in Zimbabwe; Ruth Verhey, for inviting and facilitating his morning with the women of the Friendship Bench; King’s County Hospital, for encouraging his international music therapy experiences; and finally, the women of the Friendship Bench for welcoming him, for their indomitable spirit and their music; Soli Deo gloria.
References
Aluede, C.O. (2006). Music therapy in traditional African societies: Origin, basis, and application in Nigeria. Journal of Human Ecology, 20(1), 31-35.
Backus, J. (1977). Tone quality. The acoustical foundations of music (2nd ed., pp. 107-125). New York, NY: W.W. Norton.
Burrows, D. (1980). On hearing things: Music, the world, and ourselves. The Musical Quarterly, 66(2), 180-191. doi: 10.1093/mq/LXVI.2.180
Horn, S. (2013, August). Singing changes your brain: Group singing has been scientifically proven to lower stress, relieve anxiety, and elevate endorphins. Time. Retrieved from http://ideas.time.com/2013/08/16/singing-changes-your-brain/
Saxena, S. (2014, May). Prevention of mental disorders: Opportunities and challenges from a public health perspective. In S. Galea (Chair), Preventing brain disorders: Improving global mental health. Symposium conducted at Columbia University, Department of Epidemiology, New York, NY.
World Health Organization, Mental Health Gap Action Programme. (2010). mhGAP intervention guide: For mental, neurological and substance use disorders in non-specialized health settings. Retrieved from http://www.who.int/mental_health/publications/mhGAP_intervention_guide/en/
