Woden Community Service marks a decade-long walk to better mental health outcomes

Lottie Twyford 16 December 2021
Transition to Recovery team photo

Some of the current and former people involved in getting the Transition to Recovery program off the ground: (back row) Donald Wilson, Chris Redmond, Paul Russell, Rod Mallinder, Keith Mahar; (front row) Jayne Tandl, Prue Gleeson and Maree Fish. Photo: Thomas Lucraft.

The period of care in which a person who suffers an acute mental health episode is most at risk of suicide is when they leave hospital.

This sobering fact has been driving a decade-long program dedicated to supporting people as they make that transition from care to the community through a range of practical psychosocial measures.

Woden Community Service’s Transition to Recovery (TRec) program is quite literally a life-changing and life-saving service, and one that operates seven days a week from 9:00 am to 9:00 pm.

According to mental health transitions manager Prue Gleeson, TRec works closely with the Step Up, Step Down facilities and the clinical teams at ACT Health to support people who may be vulnerable as they return home after a period in care.

The great benefit of working alongside the clinical team from ACT Health is that they can quickly and easily respond to risks and identify if and when people may need additional support.

Initially, TRec was set up following a student project that identified that people who were being discharged from hospital couldn’t access practical supports.

Prue explained they also knew that the few days after leaving hospital or a mental health facility after an acute mental health episode is when someone is at the highest risk of suicide. This is because, for many people who have experienced extreme distress, the root cause has not gone away when they return home.

“They are often going back to where that distress started and things may or may not have changed – especially if the underlying issues have not been resolved,” she said.


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What really stands out for Prue with the program is that it allows the team to be almost always there to help and it reduces the stress of needing to approach the hospital system directly.

“We walk alongside people with something they have identified themselves, so it’s very much led by what that person requires and is needing at a given moment,” Prue continued.

Usually, a team member will connect with a person before discharge to communicate with them, ask what they want to work on, and advise them of the wraparound support they will be provided with.

The support given can be anything from supporting someone homeless with finding a place to stay, securing employment or education, and linking them to resources and programs such as cognitive behavioural therapy.

“We also have mindfulness and yoga groups or other sorts of social groups which we can connect people to,” she explained.

Other times, it’s simply about accompanying someone to appointments and helping people settle into long-term routines.

TRec runs for 12 weeks, but Prue says it’s essential to ensure long-term therapeutic supports are established for the future.


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ACT Mental Health Community Coalition CEO Bec Cody says that these wraparound services are fantastic in reducing the burden on the already over-stressed acute mental health system.

“Being able to provide this service means people can get in and get the help they need for the stage of their journey they are at, rather than waiting until it becomes more severe – which in turn puts additional stress on the individual, their family, and the system,” she said.

However, she does warn that the community mental health sector remains one that is experiencing immense pressure, and it’s a pressure that has only grown since the start of the pandemic.

“There’s never enough money going around and always many people trying to access the services,” she explained.


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