In the fast-paced environment of an emergency department, a simple bucket of ice can become a lifeline.
When a patient experiencing a behavioral health crisis is growing increasingly agitated, it’s the work done by psychiatric occupational therapist (OT) Victoria Buckley, MS, OTR/L, CCAP, CDVC, that guides her nurse colleagues in the Brigham’s Emergency Department (ED) to offer an ice bucket and invite the patient to briefly submerge their hand in it.
This simple act, also known as a cold plunge, has been shown to relax the body’s stress response and ease anxiety symptoms, especially during a panic attack or similar event.
Buckley — one of the nation’s few psychiatric OTs working in a general emergency department — stepped into her role last year as part of a pilot program launched in conjunction with the opening of the ED’s new behavioral health observation unit. As a member of the unit’s multidisciplinary team, Buckley seeks to help patients with symptom management and to learn techniques and skills to reclaim their lives.
“I’m very interested in patient empowerment and helping people learn effective coping skills so they can navigate their own recovery,” she said. “And this was an opportunity to come and start something brand new in the ED to see how we can help people when they’re in crisis.”
Navigating a mental health crisis can be an extraordinarily stressful ordeal, often prompting patients to seek emergency care — be it for treatment, safety or simply a supportive presence. Because there is a nationwide shortage of inpatient behavioral health beds, patients experiencing a serious behavioral health event are directed to emergency rooms and then often wait there until an inpatient bed at a psychiatric facility becomes available. These patients can “board” in the ED for days or even weeks as they await placement.
Emergency physician Dana Im, MD, MPP, MPhil, who serves as director of Behavioral Health for Emergency Medicine and oversees the behavioral health observation unit, said Buckley has significantly helped elevate care quality and safety with her specialized skills and depth of experience.
“Victoria has taught us techniques that can be calming, and we try those strategies first so we don’t get to a point where the patient is so escalated that they require more intensive interventions like physical restraint or medications,” Im explained.
Getting Patients Back on Their Feet
In her role as a psych OT, Buckley works directly with patients to understand their challenges and collaborate on solutions to address them together.
“Occupational therapy is looking at healing through doing activities. That might be a discussion, worksheets or planning a leisure schedule,” Buckley said. “The purpose is generally to make a structure out of somebody’s day that will work for them and keep them symptom-free. It’s very individualized.”
Nancy Kelly, MS, OTR/L, clinical supervisor of Occupational Therapy in the Department of Rehabilitation Services, said Buckley’s contributions are distinct and vital.
“Psychiatric patients are a unique subset of OT,” Kelly said. “Victoria helps patients with their coping skills, insight into their current problems, maybe their family issues and their psychiatric illness, and she really tries to find solutions for them.”
Buckley has 35 years of experience in behavioral medicine, most recently at Brigham and Women’s Faulkner Hospital. Her background informs her work and has also enabled her to quickly form trusting relationships with patients whom she has cared for previously in prior roles.
“A lot of the patients I see in the ED have known me in other settings over the years,” she noted. “In those cases, I’m pretty clear on what they might need, and I’m interested in what has changed in terms of what they need. Sometimes those people are much more receptive to talking with me.”
Each situation is different, and the process of psychiatric occupational therapy is about identifying what works for each person and giving patients the tools to return to their normal life, she explained. For a patient with depression, for example, treatments tend to focus on activities that engage the mind and body. On the other hand, a patient in an anxious or agitated state might benefit from calm music and dimmed lights.
“It is a stressful environment to work in,” Buckley acknowledged. “But I think what keeps me going is that I know I’m trying to make a difference.”
Addressing the Mental Health Crisis
The Brigham’s Psych OT Pilot Program is just one way in which the Brigham is addressing a nationwide mental health crisis that has only been worsened by the pandemic.
The ED Behavioral Health Pod, though designed in advance of the pandemic, seeks to bridge the gap with better support for patients awaiting placement in a mental health treatment facility. The eight-bed pod is known as Clarendon, part of a new naming convention for the six areas that make up the ED. Those pods are now named after the Boston streets that are connected to the final stretch of the Boston Marathon — Arlington, Berkeley, Clarendon, Dartmouth, Exeter and Fairfield — in honor of the 2013 Boston Marathon bombing victims and first responders, including those in the Brigham’s ED.
The ED Behavioral Health Pod has been environmentally tailored to suit the needs of this patient population by providing safe and private space, with softer lighting and reduced noise. It is equipped with its own nursing station, medication room and a dedicated team of providers.
The ED is also currently inviting behavioral health patients who receive psychiatric OT care to participate in a research study to evaluate the program’s effectiveness.
“We’re interested in seeing what that data will look like,” Kelly said. “I’m very pleased that the Brigham is putting this kind of an emphasis on this patient population and that we were able to find somebody like Victoria.”
From what she’s seen, Buckley said psych OT has already improved outcomes for some patients.
“The response from patients has been very positive,” she said. “Some people have been able to go home instead of going to a psych hospital.”
Im said piloting the program and enlisting Buckley’s expertise have made the ED into a much safer and more healing place for these patients.
“She’s a fierce advocate for our patients,” Im said. “Her presence also helps underscore that behavioral patients require a unique set of skills that most emergency providers are not trained to do. Victoria has taught us how to better attend to our patients’ needs.”
Occupational Therapy Month is held every April to honor OTs substantial role in improving health and quality of life. In celebration of Brigham OTs, Brigham Bulletin is highlighting one of the institution’s many exceptional OTs.