Maintaining Gains: Insights from Jane Bourke, Coordinator of the Transitional Care Program

I sat down with Jane Bourke, social worker and coordinator of the Transitional Care Team. Jane has been part of the team since 2006 and works with families whose children have been discharged from the child psychiatry units, while other members of the team work closely with the schools.

She says, “The goal of the team is to maintain the gains” children made in psychiatric treatment, after they have been discharged. Her team helps to achieve this with a flexible approach, which she describes as one of the strongest parts of the program. She explains, “We’ve structured the team so that we are available just about any hour. I’ve had families that have called me late in the evening… We aren’t an emergency service, but access to support in a more… practical way is necessary.”

This transition process is not without challenges. “Regression is often a normal experience,” Jane explains, “our role is to support that regression, whether it is minimal and needs just a little boost, or whether it’s actually a full regression.” Part of the way the Transitional Care Team can provide this support is by easy access to the psychiatric team at the Jewish General Hospital.

Jane Bourke MSW, MFT. Coordinator of the Transitional Care Program

The biggest challenge for children are the changes that arise during the transition back to school. These may include social expectations and learning difficulties that surface when kids return to school. Another example is class size, “coming from a program here where the classroom is at most eight children [at the Day Hospital] going back to a classroom that is on average, 25 children” can be challenging. Part of this difficulty, is that “a teacher cannot be expected to see the cues in terms of early regression… Those little behaviors that will accelerate if not addressed.” These cues are what the childcare workers on the team look for when they observe in the schools.

Despite these challenges, the Transitional Care Team witnesses many successes. In particular, Jane recalls one boy with aggressive behavior who had serious difficulties at school and home. The team surpassed the usual 6 month contract and worked with this family for two years. Jane guesses the child “probably would have been suspended from school permanently had we not been there” and “he’s still in school. That is a success, because that is ultimately our goal, to make sure these children can graduate. And then, hopefully not accessing the [mental health care] system as often as maybe would have been needed had they not had earlier treatment.”

How can parents help with this transition? “Stay in touch” Jane says, “Our intention is to build a team around the child.”