Anxiety Disorders Residential Unit

Transcription

1 National Services Anxiety Disorders Residential Unit A service for people with anxiety disorders, including obsessive compulsive disorder and body dysmorphic disorder, unique to the United Kingdom.

2 South London and Maudsley NHS Foundation Trust» I m more motivated now than I was before. I ve also made some good connections, so I m in touch with people who understand. That, for me, has been one of the most positive things. I never felt I fitted in places before, but I was part of a family at the Bethlem. «Jo Cover illustration Healing process by Stephanie Bates, a former patient of the Anxiety Disorders Residential Unit,

3 National Services: Anxiety Disorders Residential Unit Contents Service overview 4 Our philosophy 5 Who is our service for? 6 Interventions 8 Our care pathway 14 Outcomes 16 Our facilities 18 Our team 20 Case studies 22 Referring to our service 26 3

4 South London and Maudsley NHS Foundation Trust Service overview We offer a cognitive behavioural therapy (CBT) service for treatment-resistant, anxiety-based problems, where people can stay in a residential unit throughout their treatment. Our inpatient service is specially designed for people with obsessive compulsive disorder (OCD), body dysmorphic disorder (BDD), and a specific phobia of vomiting; however, it can benefit people with all types of anxiety disorders. Our service is particularly suitable for those who have not made sufficient progress with CBT, or where local services are not available. Our service has a long history of high quality care with proven outcomes. King s Health Partners Our service is part of the Mood, Anxiety and Personality Disorders Clinical Academic Group. SLaM has joined with King s College London, Guy s and St Thomas NHS Foundation Trust, and King s College NHS Foundation Trust to establish King s Health Partners, an Academic Health Sciences Centre. King s Health Partners involves bringing clinical care, research and education much more closely together. Our aim is to reduce the time it takes for research discoveries and medical breakthroughs to become routine clinical practice. This will lead to better care and treatment for patients. Visit for more information. 4

5 National Services: Anxiety Disorders Residential Unit Our philosophy We believe that everyone has the potential to overcome their problems and increase the quality of their life, no matter what past treatment they have had or how long they have had their problems. Our programme is tailored to each person s needs. The emphasis is on discovering alternative ways of thinking, behaving and learning about their problems in order to maintain a long-term change and improvement in their quality of life. We provide a safe, caring and supportive environment for this to happen. Our patients live with other people that have similar problems, learning from each other and fostering an environment where they constantly live the therapy and their recovery. The unit is a therapeutic community where people are encouraged to help one another by noticing and naturally strengthening each other s achievements and changes in interpersonal behaviours.» Coming to the unit was one of the most important things I ve done in my life. «Joanna 5

6 South London and Maudsley NHS Foundation Trust Who is our service for? Our service provides assessment and treatment for people with treatment-resistant, anxietybased problems. It is especially suitable for people who have not made sufficient progress in their local area or where local services are not developed. Eligibility 18+ years Male or female Willing to travel home independently on weekend leave (or stay with relatives initially) Have basic self-care skills and able to self-medicate Have accommodation maintained in the community throughout the admission in order to go on home leave If a person s condition deteriorates then a bed must be made available at the person s local psychiatric hospital, or alternative arrangements made in the community within 24 hours Have a nominated local key worker (preferably a trained cognitive behavioural therapist) who can liaise over discharge and ensure adequate follow-up Willing to complete questionnaires to monitor progress; we prefer to have treatment sessions audio taped for supervision purposes Able to undertake the treatment in a language shared with one of the therapists Exclusion Current psychosis or mania requiring active treatment Current alcohol or substance dependence requiring treatment in its own right. Alcohol and substance misuse can be included if it is not the main problem, and will not interfere with CBT. However, people cannot use alcohol or illegal substances on hospital premises Severe depressive disorder as the main problem, requiring treatment in its own right Borderline personality disorder as the main problem, requiring treatment in its own right. However, we are able to accept people who self-harm so long as there is no significant risk of severe injury, and the self-harm does not interfere with other residents who may have significant fears of contamination Recent history of violence or harm to others that may jeopardise the safety of others on the unit If taking psychotropic medication, the person should be on a stable dose prior to starting treatment» The treatment at this unit has changed my life. I cannot recommend it enough. «Helen 6

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8 South London and Maudsley NHS Foundation Trust Interventions Admissions to the unit are for an initial two-week assessment period during which time people decide if they are willing and able to take part in the treatment we offer. Our therapy is based on current research and is recommended by the NICE guidelines. We continually monitor our effectiveness using questionnaires and feedback from patients and carers. Our interventions may include: A structured assessment and formulation of the person s problems by a cognitive behavioural therapist or consultant psychiatrist A minimum of two and a maximum of five weekly CBT sessions Weekly team review of progress Formal mid-treatment review by the team, including a consultant psychiatrist, every two weeks Daily occupational therapy Community group meetings Weekly life skills group Home assessments Family focused interventions Home treatment sessions, both accompanied and unaccompanied Monthly carers support group Structured assessment A three-hour diagnostic interview is conducted, to assess suitability for inpatient CBT with a psychotherapist, consultant or doctor followed by team consultation and report with full recommendations. All people suitable at assessment are given a rationale of treatment, a self-help workbook and treatment pack to start the process of treatment immediately and prepare themselves for the inpatient phase. Community group meetings This weekly community meeting aims to provide support and acknowledgement of progress in treatment as well as being a forum where current residents can resolve issues that may arise due to community living. Weekly life skills group Aiming to enhance and elaborate on individual therapy, this weekly group covers a wide range of subjects over a 12-week period. Outpatient assessment and treatment We provide an outpatient service that specialises in the treatment of habit disorders, tic disorders, and other anxiety disorders. People can attend in person or via telemedicine. Assessment includes a three-hour diagnostic interview to assess suitability for outpatient CBT, which is conducted by a psychotherapist and doctor. Treatment consists of 14 sessions, including 12 CBT treatment sessions and two follow-up sessions. Home assessments We offer a three-hour diagnostic interview with a psychotherapist, consultant or doctor, to assess suitability for inpatient CBT in the person s home or local facility followed by a team consultation and report with full recommendations. All patients suitable at assessment are given a rationale of treatment, a self-help workbook and treatment pack to start the process of treatment immediately and prepare themselves for the inpatient phase. 8

9 National Services: Anxiety Disorders Residential Unit» I have had many previous treatments for my OCD. This is the first time I feel I have conquered it. «Suzanne Family focused interventions Families are often very involved in some of the issues caused by the anxiety problems we treat. We provide individual family interventions involving relevant family members to help resolve issues. Cognitive behavioural therapy We offer patients cutting-edge CBT of proven effectiveness. Our patients learn how their anxiety problems are maintained by the threatening meanings they have developed for their symptoms and circumstances, and that some of the strategies they have used to try to cope with these may be selfdefeating. In treatment, patients develop less-threatening explanations for their experiences, which allow them to return to the activities and situations they have typically avoided. Our service provides between two and five individual, evidencebased CBT sessions weekly depending on the requirements of the person. Each patient has a main and a secondary therapist, who provides the treatment. Treatment frequently includes therapist-assisted experiments to test beliefs, and includes exposure to fearful situations including treatment in the home. CBT also addresses a person s core beliefs about themselves and the world, and each person is encouraged by their therapists to set goals. Daily occupational therapy All residents have an occupational assessment and an individual programme tailored to improving life skills. We have access to extensive facilities and have our own occupational therapist trained in CBT. As well as individual and occupational therapy, we also provide group therapy on life skills like getting back to work, diet, and relationships, as well as providing a carers support group. A wide-ranging and varied occupational therapy programme is available at the Bethlem Royal Hospital. Patients may be able to attend groups like aikido, digital photography, drumming, karaoke, organic kitchen, pottery and textiles. Occupational therapy provides people with an anxiety disorder the opportunity to explore and develop their interests. We encourage group activities where people can interact with others, which assists with building and developing social skills. Discharge and follow-up Discharge planning starts within the first few weeks of treatment, with a discharge date usually being set after the mid-treatment review. We liaise with the referring service to identify a co-therapist who can work with people after discharge. We offer two follow-up appointments within 12 months of discharge, to monitor and encourage further progress. Open carers group The carers only group provides support and information for all carers, family and friends of people with anxiety disorders. The group is facilitated by therapists and occurs monthly. 9

10 South London and Maudsley NHS Foundation Trust Weekly programme Time MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Breakfast Breakfast Breakfast Breakfast Breakfast Mosaic group project Case reviews Planned behavioural experiments with therapist and co-therapist Cookery group Behavioural activation and planning for weekend leave Community Links Out of Longfield and beyond! Lunch Lunch Lunch Lunch Lunch Individual CBT session Longfield House meeting Individual CBT session Art Open therapeutic gardening Plot to Plate Cookery planning and collecting vegetables from garden Vocational clinic Putting work on the agenda (by appointment) Individual CBT session Improving your recovery group Pottery group Individual CBT session onwards Dinner Dinner Communal dinner Dinner Dinner The above is an example, each weekly programme is tailored to the patients individual needs. 10

11 National Services: Anxiety Disorders Residential Unit An interactive art installation designed to help people with obsessive compulsive disorder (OCD) This humanistic artwork was designed by London artist Steve Caplin, to encourage residents of the Anxiety Disorders Residential Unit to throw away possessions that perpetuated their OCD compulsions into a Perspex tube held by the bully. 11

12 South London and Maudsley NHS Foundation Trust Our care model RISK MANAGEMENT Maintaining medical needs Psychological and physical risk management Discharge planning Recommendation for managing the illness in the community Appropriate use of MHA, MCA and DOLS legislation FAMILY AND CARERS Monthly carers group Providing information about anxiety disorders and treatment Providing support and access to other resources PATIENT Understanding how anxiety problems have developed and how they are maintained Developing skills to overcome them and deal with future difficulties Reclaim their life in all areas COGNITIVE BEHAVIOURAL THERAPY Evidence-based weekly cognitive therapy Home visits as part of treatment when indicated High level of specialist expertise with regular supervision Cognitive behavioural therapeutic community EDUCATION, VOCATIONAL OPPORTUNITIES Support to achieve or continue with further education Support to start voluntary work during admission THERAPIES AND SUPPORT Exercise therapists Dietetic support Physiotherapist Medical consultations Occupational therapy Vocational clinic Behavioural activation ASSESSMENT Full diagnostic assessment and individual formulations Risk assessment for all patients Weekly multidisciplinary team reviews Use of validated self-report and therapist administered questionnaires throughout treatment and follow-up WORKING WITH OTHERS Local co-therapist recognised from start of treatment Working with local CMHT and other health and social care providers Providing information, reports and liaison as appropriate 12

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14 South London and Maudsley NHS Foundation Trust Our care pathway Referral received and funding approved Review referral Recommend treatment package Not suitable for treatment report with recommendations Joins outpatient treatment wait list Outpatient treatment Discharge with relapse plan Follow-up at one, three and six months Assessment Criteria not met recommendation for alternative referral Suitable for treatment, funding approved Joins inpatient treatment wait list Treatment reviewed every two weeks Discharged with care plan approach Follow-up at one, three and six months 14

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16 South London and Maudsley NHS Foundation Trust Outcomes Our aim is to reduce symptoms and improve people s quality of life. We continually audit these outcomes using validated measures like the Yale Brown Obsessive Compulsive Scale (YBOCS), and self-report measures including the obsessive compulsive inventory and quality of life measures. Expected outcomes may include: A range of standardised measures are used, including assessment of diagnostic status, severity of symptoms, and impairment of important areas of the person s life High-end state functioning is the main aim of treatment, where we aim to achieve a level of functioning where a person is free from their anxiety disorder and their life is not adversely affected by anxiety A reduction or elimination of the need for further mental health interventions Graph 1 In the average improvement on the Y-BOCS was 14 points. In clinical terms this moves the condition from the severe category to moderate. The Y-BOCS is a recognised outcome scale that measures severity in OCD and we use an adapted Y-BCOS for BDD. Graph 2 We measure the improvement in quality of life. This graph shows the effect on work, home management, social activity, personal activity and relationships, from pre-admission through to follow-up. In our patients made clinically and statistically significant improvements on all of these measures. 16

17 National Services: Anxiety Disorders Residential Unit» I am doing things I thought I could never do, and coping better with stressful situations. «Jack 1. Average YBOCS scores for our patients with OCD admitted 2008/ YALE-BROWN OBSESSIVE COMPULSIVE SCALE 2. Quality of life improvement 2008/ REDUCTION IN COMPULSIONS REDUCTION IN OBSESSIONS PRE POST FIRST SECOND ADMISSION ADMISSION FOLLOW-UP FOLLOW-UP AVERAGE YBOCS SCORE FOR OUR PATIENTS WITH OCD ADMITTED IN Pre Post Three-month follow-up Work Social Leisure Home 17

18 South London and Maudsley NHS Foundation Trust Our facilities Our residential unit is based at Longfield House on the grounds of the historic Bethlem Royal Hospital. Longfield House is a detached house with 12 beds, where all patients live during their stay. Our property is set amongst open spaces and protected woodland. Each resident has their own bedroom with wash basin, on a same sex corridor. We have laundry facilities, an equipped kitchen and bathroom as well as dining, meeting, telephone and quiet rooms. Other onsite facilities include a gym, tennis court and indoor swimming pool. All meals, linen, duvets and towels are provided. We cater for all dietary needs, and have our own housekeeper who is responsible for the day-to-day running of the house and assisting with therapy. Our therapy offices are based at Alexandra House, also located on the grounds of the Bethlem Royal Hospital. 18

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20 South London and Maudsley NHS Foundation Trust Our team Our multidisciplinary team is under the direction of consultant psychiatrist in CBT, Dr David Veale, and principal therapist Simon Darnley. Dr David Veale FRCPsych, MD, MPhil, BSc Consultant Psychiatrist Joint Clinical Director Dr Veale is a specialist in cognitive behavioural psychotherapy. He provides a clinical service at both the Anxiety Disorders Residential Unit and the Centre for Anxiety Disorders and Trauma. You can find out more information about Dr David Veale at Research Dr Veale s research interests focus on the psychological understanding and treatment of BDD and OCD. Other roles Dr Veale is an honorary senior lecturer at the Institute of Psychiatry, King s College London. He is a trustee of two patient-led charities, OCD Action and OK2b. He has been a member of the NICE Guideline Development Group for the treatment of OCD and BDD. He was also President of the British Association of Behavioural and Cognitive Psychotherapies (BABCP) between 2006 and Background Dr Veale completed an intercalated Bachelor of Science (BSc) in Psychology at Bedford College, University of London, before graduating in medicine at the Royal Free Hospital medical school. He trained in psychiatry at the Royal Free Hospital and gained a Master of Philosophy (MPhil) degree for a randomised controlled trial of aerobic exercise in depression. Following this, he joined the Maudsley Hospital on a specialist registrar rotation. Dr Veale has been a lecturer in behavioural psychotherapy, gained a Doctor of Medicine (MD) degree for a study on possible cognitive deficits in OCD, has been an honorary senior lecturer at the Royal Free and University College Medical School, and was also a clinical tutor at the Royal Free Hospital. 20

21 National Services: Anxiety Disorders Residential Unit Simon Darnley RMN, BSc (Hons), ENB650, Dip Cog Head of the Anxiety Disorders Residential Unit Principal Cognitive Behavioural Therapist Simon Darnley is a Principal Cognitive Behavioural Therapist and Head of the Anxiety Disorders Residential Unit, managing the day-to-day running of the unit and its overall clinical programme. Background Simon has been a tutor for the Diploma in Behavioural Cognitive Psychotherapy at the Institute of Psychiatry, King s College, London. From 1999 to 2002 Simon worked as a cognitive behavioural psychotherapist and research associate at Guy s, King s and St Thomas Hospital. He has also previously worked in behavioural psychotherapy and forensic psychiatry. Other roles He has trained more than 70 cognitive behavioural therapists and has been an examiner to various cognitive behavioural therapy courses across the country. He is also a supervisor on the Improving Access to Psychological Therapies (IAPT) course. Research Research interests include OCD, irritable bowl syndrome and anxiety disorders. 21

22 South London and Maudsley NHS Foundation Trust Jo My main issue was contamination with blood in particular. I felt like it could be anywhere and everywhere... in the street, on door handles. I guess it was a little more complicated. With my OCD, I d check things quite a lot and count when I washed my hands; and I was also a mild-level hoarder. But the main thing was blood and being convinced I d get infected with HIV. It probably started at the age of 15. So, as you can imagine, I ve seen quite a few professionals over the years. I thought you had to be rich to go somewhere like SLaM. The psychologist who referred me was brilliant. She really understood OCD... she seemed to know everything you needed to know. When she asked if I wanted to go to SLaM, I just said yes, of course! I had a mixture of feelings though. I was nervous would they just throw blood on me when I got there? but I was also excited and hopeful. I moved into the Anxiety Disorders Residential Unit at the Bethlem Royal Hospital. The other people living there had a range of problems, but there was always someone with something similar going on. It was a really positive place and we all really supported each other. They devise a programme that s personal to you. I had one-to-one therapy four times a week, going down to three times a week, then two. My therapist tried to find out how my OCD had developed and how it had kept going over the years. We even drew up a big chart it s easier once you can see it all in front of you. There were educational sessions, group meetings and occupational therapy. I did pottery, art, swimming, cooking, cycling, meditation, computers... a whole host of different things. They asked what my interests were and we agreed on sessions that might be helpful as part of my treatment. I did art using red paint, for instance. I also joined the gym so I could get used to touching equipment and using changing rooms and public toilets. I had homework too, challenges that I agreed with my therapist. The experiments were things like not washing my hands after doing something specific and then writing down what I thought would happen afterwards and to what extent I believed I was going to be infected by what I d done. Like using a public toilet or getting out and about to touch things. I even slept with a vile of blood next to my bed for two weeks. 22

23 National Services: Anxiety Disorders Residential Unit It s not like you get there and they tell you to do these things straight away. There s a lot of work first, and you always agree challenges in advance. Some of the things aren t enjoyable, but something happens and you get through it. You re supported at every step. I never felt I was in danger. On one occasion, I put my hand in the toilet water and ate a biscuit without washing my hands. It s not the kind of thing you d usually do, of course, but it is about taking it to the extreme, testing things out and seeing that nothing will happen to you. I didn t think I d do that ever, even for a million pounds. But my therapist would always do the challenges before me and she had a way of talking me through them. The fact that she never got me to do anything she wouldn t do herself gave me strength. It was tough, and there were tears, but I never felt like I was in danger. I ve also recently given blood. My therapist came with me the first time, and I m due to give blood again soon. I ve also recently applied to work as a volunteer on reception at a local donor centre. I won t be in touch with blood directly, but I ll be in that environment. I mean, I couldn t walk past the clinic on the same side of the road before. Even seeing the word blood was difficult. I ve done a lot of things because of the work I did at SLaM. I have to keep reminding myself. The therapists support you at every step, and the friendships you make with people in the house are also really important. They think how you think. And there s always someone you can talk to, whether you ve had a bad day... or you want to tell someone about a good day actually. I was part of a family there. Things are still difficult, but it s early days. I live in the north of England, so it s been tough to adjust. But I have support here too; a nurse that comes around to see me regularly, and I start with a support worker this week. I also have some appointments with a psychologist coming up. I m more motivated now than I was before. I ve also made some good connections, so I m in touch with people who understand. That, for me, has been one of the most positive things. I never felt I fitted in places before, but I was part of a family at the Bethlem. 23

24 South London and Maudsley NHS Foundation Trust Emily I couldn t walk down the street normally. I m 39 and I ve had obsessive compulsive disorder (OCD) for about seven years. My OCD came on late and suddenly, which is unusual. My biggest problem was that I couldn t walk normally. At first it was along the pavement, but then inside, up and down stairs, on grass, anywhere. I felt I had to avoid drain covers and marks on the ground, different shades of colour, and even tiny specs. I constantly had to retrace my steps. I knew it looked strange, but that didn t stop me. I was living in central London and it was such an effort to go out that I started going no further than the corner shop to buy food. Later I began to avoid doing even that; even the buying process became a problem. I moved back to my home town and I took taxis even if I was just going round the corner. I was physically healthy, which was a blessing, but daily life was hugely restricted. It wasn t feasible to live with others. When my landlady asked me to move out of the room I was living in, I began to look for somewhere else to live. I realised I couldn t live in shared accommodation because my problem would impinge too much on other people. I moved back into my parents house for five months. It was very difficult for them; I remember being extremely demanding and we had huge arguments. I had become really thin because buying food had been difficult. I d made enquiries about the Anxiety Disorders Residential Unit, but I was told that I d have to put on weight before they would admit me quite the right thing in retrospect. I ended up on an eating disorder unit for five months. Then when I finally got to the Bethlem, things didn t go as I expected. To be there, you have to be 100% committed to do the work towards recovery, and halfway through my stay I was sent home because I wasn t progressing enough. I was readmitted a year later, thank heavens, but I was distraught at the time because I d set all my hopes on being there. The intensive CBT at the Bethlem was just what I needed. Like everyone else there, I d had lots of cognitive behavioural therapy (CBT) before, but once a week hadn t helped me. My OCD would improve for a short time after each session, but I found it impossible to keep it up. The first time I was able to work intensively on CBT with the support I needed was at the Bethlem. The unit is an environment where you can focus on recovery 24 hours a day. There is always someone around to encourage you and everyone understands the problem. 24

25 National Services: Anxiety Disorders Residential Unit During the day there is a programme of different activities which complement the therapy sessions. You are constantly challenging your OCD, as well as keeping busy and doing things to prepare you for getting back into the way of everyday life. We did cookery where we would plan what to cook, go out and buy ingredients and cook a meal once a week. This all sounds simple, but these were the sorts of things which were difficult. The therapy itself is first class; there is a strong focus on doing. Therapists set individual homework tasks, like going to the local shops or travelling on public transport. Then you have the opportunity to discuss your tasks and report back on any difficulties. This constant help made all the difference. The staff at the unit have a perfect understanding of what patients are going through. I was also extremely impressed by their commitment. Treating OCD is about getting down to the nitty-gritty and actually doing activities with the patient, which they are prepared to do. It s a residential unit, which is very important. It means you retain a level of responsibility and independence. We weren t there to be molly-coddled, but to learn to function normally again. I walk around freely now. My mind is much more free. My quality of life is incomparably better now I can do so much more. Also, my mind is clearer. OCD used to engulf me. Now I can give myself new objectives, not related to my OCD, which is very refreshing. I am cycling again, which is something I haven t done for years. There is a weekly cycling group at the Bethlem, where I got on a bike again. I pretty much grew up on a bike, but cycling became impossible because I would have to go back over every little thing. I feel like a capable person again. I feel a real sense of freedom since I left the Bethlem and I can see many possibilities before me. I did some voluntary work at the unit which made me feel capable and confident. I m organising my life again now, and I m looking forward to getting back to work as soon as possible. I honestly can t see how I would have recovered without the intensive help I received at the unit, it was just too difficult on my own. Things only really started to change when I was there. I only wish I had got to the unit sooner. I m eternally grateful for my time at the Anxiety Disorders Residential Unit and for the commitment and skill of the brilliant therapists there. I can t imagine a better place to recover. 25

26 South London and Maudsley NHS Foundation Trust Referring to the unit Referrals are accepted from consultant psychiatrists, GPs and community mental health teams. We accept referrals from the National Commissioning Group (NCG) scheme for severe OCD and BDD. Please see our website for full information on the NCG referral process. Anxiety Disorders Residential Unit Alexandra House Bethlem Royal Hospital Monks Orchard Road Beckenham BR3 3BX T: F: A214 Upper Elmers End Road Bethlem Royal Hospital Eden Park Rail Links Way S Eden Park Road B230 A214 S Eden Park Road Beckenham Road Monks Orchard Road West Wickham Rail Manor Park Road Ravenswood Crescent Station Road A232 Wickham Road High Street A232 26

27 It s easier than ever to find out more about our national services. Make secure online referrals Access detailed information about each of our national and specialist services, including service contact details View care options, interventions, outcomes and costs Read profiles of our experts Catch up on our latest research Discover the experiences of people who have used our services Sign up for our e-newsletter Offering over 50 national and specialist services for adults and children, accepting referrals from across the United Kingdom. Visit today. Printed on Soporset by Crucial Colour Photography: davidhares.com Design: piersanddominic.com Published: February 2011

28 Anxiety Disorders Residential Unit Alexandra House Bethlem Royal Hospital Monks Orchard Road Beckenham BR3 3BX A national service for severe anxiety disorders, in a residential setting that leads to significant improvements in quality of life. «Dr David Veale