The play "Fear and Shame" explores themes of mental illness and stigma within The Macedonian community. This play was written by Dushan Ristevski, a Mental Health Counsellor with the St George Mental Health Service following a series of research projects and clinical experiences. The research highlighted widespread negative views and discrimination regarding mental illness within the Macedonian community.

The un-intrusive theatre based approach was seen as one of the most culturally appropriate and widely accessible methods to address these issues to all members of the community. At the end of 2006 the play was published in the Macedonian language and now it is available as a resource to carers, consumers and the general Macedonian community. In addition to the local artists, consumers and carers were engaged in the production and the play was subsequently performed by a community theatre group to large audiences in 2008.

The Project was aimed at promoting awareness and reducing stigma within the Macedonian Community regarding mental health issues. An increased community acceptance and understanding of mental illness as well as improved engagement with appropriate services is the anticipated outcome.

Data collected in the 2003 research, revealed widespread negative views concerning mental illness within the Macedonian community. The Mental Health Services in St George initiated a series of projects over the next 3-4 years looking at attitudes within the Macedonian community towards mental illness and mental health services. These projects uncovered widespread negative views, with people with mental illness being viewed as having a personal failure or weakness. Fear about the possibility that others will find out about the illness is based on the Macedonian community's view of itself as a cruel and discriminatory community, intolerant of issues relating to mental illness. The impact of these views and the associated stigma resulted in poor engagement with Mental Health Services.

As part of the research, 100 people from the Macedonian community participated in interviews: 24 consumers, 22 carers, 54 community members, including 12 key informants who had no personal contact with the Mental Health Service. Analysis of the Health Care Interpreting data revealed very few occasions provided for the Macedonian speaking consumers and carers. This demonstrated a reluctance on behalf of clients and families to use interpreters and reflected a lack of understanding the importance for using interpreters when discussing mental health issues.

Service trends within Mental Health indicate that people of Macedonian background are treated involuntarily and more often when their illness is in the acute stage, rather than during early stages of illness or for continuing treatment through the Community Mental Health Centres.

This project has involved developing crucial partnerships between the mental health service, community organisations and community members, including the consumers and carers.

This approach to service delivery which involves clinicians and the broader community has been shown to be useful in providing a more integrated approach to service delivery and minimising service gaps while improving clinical engagement.

There was active involvement in engaging Government Authorities (Community Relations Commission of Multicultural NSW) the Local Governments in the St George area, Non-government  organisations (Macedonian Literary Society and the Australian-Macedonian Theatre of Sydney), the Macedonian community (Macedonian Orthodox Church, St Petka of Rockdale, Macedonian Orthodox community of Sydney), medical professionals, carers and consumers for the production and staging of the play.

Strategic Direction 2 - Create better experiences

Reduction of stigma will encourage consumers and carers to seek treatment in the early stages of the illness, prior to involuntary treatment Clinicians, local Macedonian community organisations, consumers and carers worked in partnership to reduce the stigma in the community by staging the play "Fear and Shame".

Strategic Direction 3 - Strengthen primary health

The art-based approach is informative, educational and culturally appropriate and thus encourages engagement and early intervention. This will lead to improved health outcomes, reduced avoidance and hospital admissions.

Strategic Direction 4 - Work in partnership

The Mental Health Service has engaged the Macedonian community and Non-government organisations to produce the play.

Strategic Direction 5 - Benefits and costs effectiveness

Community organisations operating on voluntary basis effectively participated in reducing the stigma in the community. To date, 1500 people have seen the play.

Strategic Direction 6 - Sustainable workforce

The written work and produced DVD of the play "Fear and Shame" will be used as an on-going educational resource, training tool for mental health professionals, GPs and community workers as well as carers and family members.

The St George Division of Mental Health chose an innovative theatre based approach to reach more members of the Macedonian community. It has been established that this was the most culturally appropriate medium for this purpose as the Macedonian community has a strong history of participation in theatre. Some clinical staff as well as management were involved in conducting and evaluating the research, promoting mental health issues and services via community groups, community services and the media. They have also been actively involved in engaging Government Authorities (Community Relations Commission of Multicultural NSW) the Local Governments in the St George area, Non-government organisations (Macedonian Literary Society and the Australian-Macedonian Theatre of Sydney),  the Macedonian community (Macedonian Orthodox Church, St Petka of Rockdale, Macedonian Orthodox community of Sydney), medical professionals, carers and consumers to take an active role in supporting and staging the play. The theatre cast consists of various theatre professionals, artists, a local general practitioner, a consumer and carers.

In 2006-2007, "Fear and Shame" was successful in attracting a funding grant in recognition of its focus on promotion of community harmony and the active community participation of people from multicultural backgrounds. This initiative has also received outstanding support from senior management and colleagues in Mental Health at St George (Central Network) and at Area level and from the area Multicultural Health Service as well as countless community members and most importantly those people experiencing mental illness and their families and carers.

The production of the play has so far been seen by more than 1500 people. The media (electronic and written) joined the campaign against the stigma in the community and the promotion of sound mental health has reached thousands of members of the community who live in Sydney as well as other regions in NSW and interstate. There has been extensive coverage by the mainstream local newspaper (St George and Sutherland Leader, as well as in the Ethnic Community Council's Newsletter, Chief Executive Officer’s Newsletter).

We have had highly positive feedback from the Macedonian community as well as from other Non-government service providers, health professionals, consumers and carers. The Macedonian Community in May of this year has awarded the play with the Golden Sun Community Award in the Literature and Culture Category. The play is to be performed during the Mental Health Week in October 2008 in Hurstville (2 productions), Queanbeyan (1 production) and Melbourne (2 productions).

The production of the DVD will be available for other audiences and the play is expected to be seen by many more members of the Macedonian community.

This project has involved developing crucial partnerships between the mental health service, community organisations and community members, including the consumers and carers. This approach to service delivery which involves clinicians and the broader community has been shown to be useful in providing a more integrated approach to service delivery is also useful in minimising service gaps and improving clinical engagement .The theatre production creatively explores mental illness and treatment. It has promoted community awareness of mental illness and community understanding of the impact of stigma on those affected.

The St George Mental Health Service has published the play and produced a DVD which is available as a resource and educational material for consumers, carers, general community and health care professionals. The English version of the play will be shortly published and will be available to the general community not only in NSW but also interstate.

By choosing a theatre-based approach in addressing the stigma in the Macedonian community, producing the play in partnership with the community, engaging the members of the community, consumers and carers we have shown that this innovative approach can be used as a model and can easily be implemented by other communities and health services throughout NSW and interstate.

There are possibilities that the play, following its English publication, will be produced by a mainstream theatre and screened for a wider television audience.

• Terry Clout, Playwright Health Counsellor Eases Stigma, The News – a weekly newsletter, 14.05.2008.
• Ethnic Communities' Council of NSW, ECC News Online: Macedonian play: "Fear & Shame" putting mental health issues in the spotlight, 19.04.2008.
• Deborah Field, Exposing Illness Stigma, St George & Sutherland Shire Leader, 19.12.2006.
• Deborah Field, Play Dispels Worries, St George & Sutherland Shire Leader, 10.04.2008.
• Dushan Ristevski, Fear and Shame, Macedonian Literary Association, 2006.
• St George Division of Mental Health, Macedonian Mental Health Project: Understanding the attitudes and beliefs of the Macedonian Community about mental illness, November 2003.

Bi-lingual Counsellor, Rockdale Mental Health
South Eastern Sydney Illawarra Area Health Service
Phone: 02 9567 6500

Director, Mental Health
South Eastern Sydney Illawarra Area Health Service
Phone: 02 9350 2531

Continuing & Community
South Eastern Sydney Illawarra Area Health Service
Phone: 02 9350 2506