Token economy

Aim

• To manage schizophrenia rather than treat it, i.e. using positive reinforcement

• Behaviours are encouraged by the use of selective reinforcement based on operant conditioning

• Focus on the negative symptoms of sz

Method

• 'Normal’ behaviours that are desired are positively rewarded, with the aim of that behaviour being repeated.

• Desirable behaviours are rewarded with a plastic token, a secondary reinforcer that has no intrinsic value, but can be exchanged for primary reinforcers e.g. TV time, cigarettes

• These primary reinforcers must be viewed as highly desirable by patients

• In a psychiatric hospital, negative reinforcement may also be used, as privileges/tokens may be removed until the patient performs normal behaviour

Alogia

• Not replying when someone else speaks to them

• Receive a token when they give a coherent/reasonable length reply to a question

Flat affect

• Dulled emotional expression

• Token taken away every time they have a dulled expression

Avolition

• Not engaging in hospital activities e.g. playing a sport

• Receive a token when they engage in activities

Apathy

• Refuse to take part in CBT sessions

• Receive a token for every session they attend

Research Support (+)

• Allyon & Azrin: 45 female chronic SZ patients, averaging 16 years of hospitalisation. Many screamed for long periods, were mute, assaultive and no longer ate with cutlery

• Following a TE, they were carefully reinforced with tokens for their ward work and self-care behaviours which were exchanged for a given privilege e.g. listen to music, rent a private room, see a social worker)

• This led to a dramatic improvement in self-care behaviours, as when the system was removed, these behaviours disappeared

Effectiveness (+)

• May be useful for patients with mild symptoms

• They may need some motivation to enable them to cope with everyday challenges like social interaction and personal hygiene

Ethics (-)

• Gives professionals/medical staff significant power of control over the behaviour of patients, imposing a ‘norm’ in the ward that some may argue is inappropriate e.g. a patient may not want to dress a certain way for the day

• This restricts personal freedoms, which may aggravate more distressing symptoms, especially if they are not performing well and are not earning the required tokens that are pleasurable and escapist for the patient

• This has led to legal action in the past, as families are not okay with personal liberties being taken away from the patient

Reductionist (-)

• Focus only on external behaviour change, without addressing underlying cognitive, emotional or biological causes of sz

• Limits the long-term effectiveness, as behaviour may not generalise outside of the institutional setting once reinforcement is removed