Provision of buzzers
14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
15. Miss K complains her therapist (a consultant psychologist) did not action an agreement made in April 2023 to order her some buzzers to use in her EMDR therapy. Miss K says her therapist instead used a method of tapping on her hands and legs which she found triggering.
16. Miss K tells us she feels the Trust should have ordered her the buzzers as a reasonable adjustment as she is mentally unwell and undergoing an assessment for autism and ADHD. She also told us she has physical health needs.
17. The NICE guidance for PTSD recommends the use of bilateral simulation when providing EMDR therapy. It recommends this will normally be through eye movements but also recommends using other methods, including taps or tones, if the patient prefers or if appropriate. The guidance does not specifically recommend the use of buzzers for this.
18. Miss K says she first requested buzzers at her initial psychology assessment on 19 October 2022. There is no mention in the notes from this appointment that Miss K requested the Trust order her buzzers for her EMDR therapy. It is possible her therapist did not document this request.
19. We have weighed up Miss K’s account and what her therapist documented in the medical records from this time. There is nothing in either of these two accounts which sways us to deciding that one account is more plausible than the other. As such, we do not feel we can take a view on whether Miss K requested buzzers at this time.
20. We can see that when Miss K started EMDR with the Trust on 4 January 2023, the consultant began using a method known as the butterfly taps method as they noted she had previously not been able to cope with the eye movements method. Miss K reported she was struggling with this form of bilateral simulation.
21. Miss K’s therapist switched to a method where a book was placed on her knees as a barrier. The therapist reported Miss K coped better with this and reported feeling calm at the end of the session.
22. There is no documented conversation of Miss K requesting buzzers at this appointment. This contradicts what Miss K tells us as she advised that she requested the buzzers during this appointment also. Regardless, it seems that Miss K appeared to cope with the new form of bilateral stimulation at this appointment. It appears the therapist was acting in line with the NICE guidance by using another method which appeared to work for Miss K at the time.
23. There was no further mention of any concerns until Miss K’s appointment on 12 April. Her therapist documented Miss K was struggling with the EMDR and said she found the taps difficult to do. They documented she advised she had previously used buzzers with her private therapist.
24. Miss K’s therapist noted they advised her they did not have buzzers but would look into this. We can see no evidence in the medical records that Miss K requested these as a reasonable adjustment but that it was because she found the butterfly taps method difficult.
25. On 26 April, the therapist noted they advised Miss K they would purchase her some buzzers but there would be a wait. They did not state how long this wait would be. They documented that Miss K agreed to continue with the tapping method in the meantime. It is unclear what happened following this as the Trust has provided unclear and contradictory information to Miss K.
26. On 19 July the therapist noted Miss K raised that the buzzers had still not been provided. The therapist noted in the medical records she advised Miss K the buzzers were out of stock and she was waiting for them to come back into stock. However, the Trust advised us the therapist looked into ordering the buzzers initially but then decided not to order them as they are not recommended.
27. Having carefully considered what happened, we do not feel there are indications of failings in the Trust not providing buzzers for Miss K as they are not recommended within the NICE PTSD guidance. There is no requirement for the Trust to provide these and it tried a range of other options for her when she found the initial method difficult.
28. However, we can see indicated failings in how the therapist communicated with Miss K about the buzzers. As the therapist had advised Miss K it would order them, they should have honoured this agreement or provided her with a clear and timely explanation as to why they could not do. This was not in line with HCPC guidance which says psychologists should communicate effectively.
29. It is likely that had the Trust done this, Miss K would still have been distressed at being told the buzzers would not be ordered. However, it is possible this distress may have been reduced if the Trust had clearly communicated to her. The Trust has agreed to undertake some further work to address this poor communication.
Continuity of care
30. Miss K says the Trust did not offer continuity within her course of treatment as her therapist was frequently on sick or annual leave.
31. The NICE guidance for post-traumatic stress disorder does not advise how many or how frequently EMDR sessions should occur. It says EMDR should typically be provided over eight to twelve sessions and that these should be provided in a phased manner.
32. We note from the records it appears the plan was for Miss K to have weekly EMDR sessions. We can see that in total Miss K had 18 EMDR sessions between 4 January and 19 July.
33. We can see two occasions where there appeared to be long breaks in Miss K’s therapy. The first was following Miss K’s appointment on 25 January when her next appointment was not offered until 22 February.
34. This meant that three sessions which would usually go ahead would not due to Miss K’s therapist taking planned leave. The Trust then cancelled the appointment on 22 February due to unforeseen circumstances which meant the therapist had to take unexpected leave.
35. The Trust then did not provide Miss K with an appointment until 8 March which meant Miss K missed five sessions in total. In its complaint response, the Trust acknowledged this was a considerable gap and apologised for the disrupting effect this would have had on Miss K’s progress in therapy. It said the therapist did apologise and spent some time at the next session trying to repair the damage to their working relationship.
36. The second occasion were there was a gap was following Miss K’s appointment on 19 June when the Trust did not offer her another appointment until 21 July. This meant that three sessions in between would not go ahead and was again due to the therapists planned annual leave.
37. We asked our adviser what would usually happen when a therapist takes annual leave. Our adviser explained that unless a therapist was on long term sick or off for a long period of time you would not replace them with an alternative therapist. They explained it is expected a patient would be able to tolerate breaks in therapy. They said Miss K had other support systems available to her and so was not completely without support in the meantime.
38. Taking this advice into account, we cannot see any indicated failings in this area of the complaint. The NICE guidance for this treatment does not say how frequently appointments should occur and the advice from our adviser suggest patients are expected to tolerate breaks in therapy. We are in no way underestimating how difficult Miss K found these breaks though.
Attitude of therapist
39. Miss K says her therapist spoke to her in an authoritative way which she found triggering. We cannot see the Trust addressed this when it responded to Miss K’s complaint.
40. Our guidance says that we may decide not to investigate a complaint where an investigation would not be practical or would not reach a satisfactory conclusion.
41. We consider we would be unable to reach a robust view on this issue. This is because we do not have an account from the therapist and so we only have Miss K’s account of how she found the appointments.
42. It is likely that too long has now passed since the appointments for the therapist to give an accurate account of what occurred. Even if we had this, it would still be difficult for us to take a view on the tone or manner that they spoke to Miss K. This is because we were not present at the time of the appointments.
43. As such it would not be practical or proportionate to investigate this issue further. We appreciate this will be a disappointing outcome for Miss K.
Referral to the crisis team
44. Miss K complains the Trust refused to refer her to the crisis resolution and home treatment team (CRHT) on 26 July.
45. The NICE guidance for borderline personality order advises what to do when a patient with borderline personality disorder presents during a crisis. This says to:
• explore the person's reasons for distress • maintain a calm and non-threatening attitude • use empathic open questioning, including validating statements, to identify the onset and the course of the current problems • seek to stimulate reflection about solutions • avoid minimising the person's stated reasons for the crisis • refrain from offering solutions before receiving full clarification of the problems • explore other options before considering admission to a crisis unit or inpatient admission • offer appropriate follow-up within a time frame agreed with the person
46. We can see from the records that Miss K spoke to the team lead at the assessment centre. She advised that she was in crisis and that she needed the CRHT. She advised she had cut her right leg and that she would take an overdose but did not want to get into this situation. She said she would go to A&E if she had to.
47. We can see that following discussion about the issues, the team lead did not recommend referral to the CRHT at the time. They documented they felt Miss K was able to use her management tools for distress and needed some time to de-escalate at home. They felt additional workers would not be helpful and explained the other options she had for support at the time.
48. The team lead noted Miss K left this appointment without incident and that she would be contacted the following day. The team carried out a risk assessment noting that Miss K had implied suicide but had no plans. They noted she had a history of this type of behaviour but had taken an overdose in her early 20s and then sought help.
49. Our adviser said the CRHT team was not indicated at this point. They said that in this instance it is not clear what the crisis team would do other than suggest treatments already used in the past. The notes indicate that even though the patient was threatening self-harm the team lead not think Miss K was at risk of suicide.
50. It appears overall that the Trust acted in line with the NICE guidance which advises to explore other options before referring a person to the CRHT. The Trust also offered an appropriate follow up in line with this guidance. We can see no indications of failings here.
Decision to stop EMDR
51. Miss K complains the Trust stopped her therapy and declined to provide further EMDR stating she could not handle it.
52. The NICE guidance for post-traumatic stress disorder advises to:
• help the person manage any issues that might be a barrier to engaging with trauma-focused therapies, such as substance misuse, dissociation, emotional dysregulation, interpersonal difficulties or negative self-perception • assess the need for further treatment or support for people who have not benefited fully from treatment or have relapsed.
53. We can see that Miss K attended her appointment on 19 July following a break due to her therapist’s annual leave. Miss K expressed in this appointment that she felt she could not do the therapy anymore as she could not handle the breaks. Her therapist explained that all therapists have breaks and that she would need to be able to tolerate this.
54. During this appointment the therapist noted they discussed that they felt maybe Miss K needed another type of therapy to learn to cope with the breaks and manage her emotions such as the Thinking Well. Thinking Well is a service which offers support to people with complex emotional needs. The therapist documented Miss K refused this.
55. Following this, there is a note in the medical records on 26 July stating that that Miss K advised she did not want to continue with her therapy. Miss K disputes this stating that she only asked for a different therapist and not that she wanted to finish EMDR.
56. At this point, the therapist documented they felt Miss K would benefit from the Thinking Well service as she had struggled with EMDR therapy, the breaks in therapy, and was finding several issues in her life very difficult. They noted they felt she needed help with managing her emotions.
57. The therapist explained this to Miss K by telephone and follow up in a letter on 7 August. The psychologist advised in this letter that Miss K could be further considered for EMDR when she was more able to manage external stressors and any breaks in therapy.
58. The Trust agreed the EMDR was not benefitting Miss K and that her treatment should be more focused on emotional regulation as that was what seemed to be preventing the treatment helping.
59. This seems to be in line with the NICE guidance which recommends helping people struggling with barriers to the therapy (including emotional dysregulation) and to assess the need for further help or treatment for these. We can see no indications of failings in the Trust’s decision not to provide further EMDR until Miss K had chance to explore these barriers.