Stanford Social Innovation Review
August 2018
Harriet Nakalyango sells water and farms a small plot of land to make a living on the outskirts of Kampala, Uganda’s capital. After she married at age 16 and had four children, her husband “started boozing and beating [her] from morning to evening,” she
says. The physical violence took an emotional toll. “I was sincerely sick. I was crying
every day. I was not eating. I wouldn’t let my kids go out,” she says. “They used to cry and
I used to cry. I wasn’t working and stayed at home. I was almost dying with kids. That
was the end of me.” Nakalyango fell into an eight-year depression.
GO TO ARTICLE
In 2015, a friend told Nakalyango about StrongMinds, a US-based nonprofit that
launched its pilot program in Uganda in 2014. StrongMinds trains mental health
facilitators to lead peer-group therapy sessions for women with depression in poor
communities in Kampala. According to the World Health Organization
(WHO), depression affects 322 million people worldwide and is also the leading cause
of disability globally. But fewer than half of the people suffering from it receive treatment —especially in countries lacking a solid understanding
of mental health. In developing countries like Uganda, up to 90 percent of
people who suffer from depression don’t seek treatment. Social stigmas and lack of awareness, resources, and health-care providers are just some of the barriers they confront.
A StrongMinds facilitator leads a peer group therapy group in Kampala, Uganda. Photo: Amy Yee
In Africa, people with mental health issues are often ignored or ostracized, and resort to
being “treated” by witch doctors. In Uganda, where less than 1 percent of GDP goes to
mental health care, reports estimate that approximately 30 psychiatrists exist among
a population of more than 44 million.
Discouraged by the lack of options for people with mental health issues in Africa, Sean Mayberry founded StrongMinds in 2013. Mayberry had worked in Africa for a decade on implementing AIDS/HIV and malaria programs. Prior to starting StrongMinds, he was country director for Population Services International in Democratic Republic of the Congo. He also served as chief operating officer of VisionSpring, an eye-care nonprofit serving developing countries, and as chief executive of FXB, a global poverty-alleviation nonprofit based in New York City.
A life-changing encounter in Uganda with an “adolescent boy with a mental illness,”
Mayberry recounts, “finally galvanized me to understand that someone had to do something about creating mental health access in Africa. If I didn’t do it, who would?”
He continues, “I worked in the Congo for years to improve physical health—in malaria
programs, HIV prevention, and clean water. I saw over and over my African friends, colleagues, and clients who suffered from mental illnesses [unable to] access care—and
I could do nothing as a leader of a public health organization to help them. … I found
this incredibly frustrating.”
Mayberry also had a personal connection to mental illness. “I grew up with parents
suffering from depression, and I have very close family members today who suffer from
depression,” he explains. “I understand what depression does to individuals, to mothers,
to children, to families—I understand that depression is truly a debilitating disease
that, left untreated, tears people down and in many ways stops them from living to their
full potential.”
THE STRONGMINDS MODEL
StrongMinds uses the interpersonal group-therapy technique—also known
as group interpersonal psychotherapy (IPT-G)—to help group members identify
and manage their problems without medication. During weekly sessions of approximately 90 minutes over three months, groups of about a dozen women talk through their problems with a facilitator trained in IPT-G. The first few sessions focus on
building rapport with group members to establish trust and emotional comfort. In the
second of the program’s three phases, women make suggestions to one another and begin to understand the triggers of depression. In the third phase, facilitators teach them to recognize and respond to those triggers. Women who want to join StrongMinds take
the PHQ-9 survey, the standard patient questionnaire used to assess depression,
to receive a preliminary diagnosis. Those found to be severely suicidal are not a good
fit for peer-group therapy and are referred to clinics with mental health facilities.
StrongMinds focuses on women—who suffer unipolar depression at twice the
rate of men, according to WHO’s report on gender disparities and mental health.
Potential causes for this difference include gender-based violence, and economic and
social inequalities. In Uganda, these range from poverty to women’s shouldering the responsibility of caring for their children and families. StrongMinds also piloted programs for men, but, because attendance was low, the programs were subsequently cancelled.
When StrongMinds launched in Uganda, people were suspicious of a new organization
coming into their community. Some feared it was a religious cult. Some women
who wanted to join faced resistance from their husbands and other family members
who did not want them to talk to others about their problems. To overcome these
barriers, mental health facilitators spent time with community leaders and held public
events to raise awareness about depression and explain their work. Mental health
facilitators stress confidentiality, even though women often come from different
nearby communities and don’t necessarily know one another. According to Dena
Batrice, executive director of StrongMinds Uganda, about 20 percent of women drop
out of the program, although she says the reasons for this rate remain unclear.
For Juliet Nsubuga, the facilitators’ continued presence in her community convinced
her to join a meeting after she originally dismissed the program. Nsubuga was married
at 14 and then widowed after having seven children. Her deceased husband’s family took
most of her property and told her to remarry.
Instead, she eked out a living as the owner of a small shop, but thieves robbed the store and took everything. She reached a breaking point when her 27-year-old son died in an accident and her three daughters—ages 17, 15, and 13—became pregnant. Nsubuga used to serve as an informal leader in her community, but her daughters’ unplanned pregnancies made her feel ashamed and caused her to withdraw and fall into depression. “I hated myself. I thought my life was over,” she says.
In Nsubuga’s group, women talked through their problems. One woman was
distraught because her husband harassed her because she couldn’t get pregnant. Lack of
money was a common challenge among the women. Group discussions covered possible
financial solutions, including earning money from selling vegetables and braiding hair.
In therapy, Nsubuga admitted she “hated her children,” but the group encouraged her to
re sume communication with them. Nakalyango’s experience is similar to Nsubuga’s. By sharing their own stories of depression, the women in her group affirmed
that she wasn’t alone in her struggles. She learned to communicate better with her
husband, which improved her relationship with him. Nakalyango recalls something
the facilitator told her group: “One stick is easy to break. But many sticks together are
difficult to break.”
After their sessions ended, both Nsubuga and Nakalyango completed 14 weeks of training from StrongMinds to become volunteer peer facilitators. “I was in the deep,” explains Nakalyango. “If I [hadn’t gotten therapy], I’d be dead now. I know many people
who are suffering. It was medicine for me. What they did for me, I also have to do it.”
TWO MILLION WOMEN BY 2025
Starting StrongMinds was no easy task. Because mental health is more difficult to
quantify and explain than physical health interventions, such as vaccinations, Mayberry
faced the initial challenge of attracting donors, who were more focused on highly visible
health crises like HIV/AIDS and malaria.
“Until StrongMinds started, mental health programs and illnesses were viewed
as complex, complicated, slow to work, and even mysterious,” Mayberry says. “Donors thought treating them would take years and massive investments in hospitals, doctors,
and nurses, and that even then there would be no clear deliverables.”
Mayberry launched StrongMinds with family savings and worked unpaid for the
first two years. Today, financial support for StrongMinds comes from private donors
and philanthropies such as Mulago, CRI Foundation, Elmo Foundation, and Draper
Richards Kaplan Foundation.
A StrongMinds member stands in front of a therapy group in Kampala, Uganda. Photo: Amy Yee
“Our first donors came on board because I knew them—they supported VisionSpring,
so they knew me and believed in me,” says Mayberry. “They also were forward-thinking
and understood that mental health was a neglected health area that needed support.”
Kristin Gilliss, a senior investment partner at Mulago, explains that Mayberry is “a
proven implementer—he built teams and scaled operations for organizations ranging
from Intel to VisionSpring across Asia and Africa. We look for people who are
irrepressible.”
Both StrongMinds’ effectiveness and its future expansion plans are due to its
group-therapy model, which is inexpensive to scale. In its first year, 514 women in Kampala participated in group therapy. In 2017, more than 15,000 women were treated. Since the 2014 pilot program, more than 25,110 women have successfully gone through StrongMinds treatment, and approximately 86 percent of those who completed the program say they are no longer depressed. StrongMinds also reports that about 80 percent of groups continue to meet informally after their program’s
conclusion.
The nonprofit now aims to reach two million women by 2025. It wants to expand
to other countries in Africa and work with governments and big NGO partners to meet
its ambitious goals. Mayberry sees this objective as integral to development in general.
If women are struggling with depression, they “are held back, and development efforts
are wasted,” he says. “By reducing and eliminating depression in Africa, we pave the way
for all other behavioral change efforts to be more efficient and impactful.”
Amy Yee 