token economies for maintenance of SZ

general idea and three main steps

• These are a form of behavioural therapy where desirable behaviours are encouraged by the use of selective reinforcement.

• It is based on operant conditioning and is used for management (not treatment) of schizophrenia.

• It involves three main steps:

  • Identifying the undesirable/maladaptive behaviour.

  • Identifying the reinforcer that maintain such behaviour.

  • Restructuring the environment so that the undesirable behaviour is no longer reinforced .

where are they mainly used

• Clients set target behaviours that they believe will improve the patients’ engagement with daily activities.

• Token economies are used mainly in psychiatric hospitals, with patients in long term care. The goal is to enable the patients to leave hospital and function independently.

  • Not used as often anymore as SZ is not treated with long-term hospitalisation as often (more community-based care, ethical issues with giving rewards to people with mental disorders)

process

• Token economies are used to combat negative symptoms. The desired behaviours may be as simple as a patient brushing their own teeth or could be more socially oriented e.g., helping another patient. Token economies are also used to encourage patients to comply with drug regimes.

  • Undesirable behaviour is repeated because it is being reinforced (particularly in patients who are 'institutionalised) -> patients likely to develop bad hygiene and remain in pyjamas all day

  • Desired behaviour is displayed -> tokens are given immediately as reinforcement, immediacy is important as it prevents delay discounting (reduced effect of delayed reward)

  • Tokens are secondary reinforcers (generalised reinforcers) then can be exchanged for priveleges (primary reinforcers)

  • Basic commodities like food, water and sleep are human rights - cannot be withheld from patients

• Institutionalisation may develop - Matson et al 2016 identified three categories = personal care, condition-related behaviours and social behaviour

strength 1 of token economies

• A strength of the appropriateness of their use in institutions is that they make wards calmer and more manageable for staff.

• A major review of treatment recommendations by Lehman (2004) advocated the token economy system as being useful for promoting changes in behaviour in institutional care settings.

  • By extension, the positive behaviours are encouraged when displayed meaning that wards are calmer and more manageable for staff, promoting positive interactions between staff and inpatients and a more positive environment for patients

• However, it is important to note that an issue of appropriateness is that there are ethical concerns.

  • This is because they give clinicians power to control people. This is problematic as if target behaviours are not identified sensitively, it may mean people have privileges taken aware unfairly.

• Therefore, this implies that although token economies have positive consequences for making institutions calmer and more manageable, the behaviours people receive tokens for must be individualised in order for their use not to be violated.

strength 2

• There is research to support the effectiveness of token economies in managing the negative symptoms of schizophrenia in institutions.

• Ayllon and Azrin (1968) examined the use of token economies in 45 female schizophrenic patients who had been institutionalised in a hospital in Illinois, for an average of 16 years.

  • Before token economies was introduced, behaviours such as screaming, not using cutlery while eating, and wearing undergarments over their clothing were common.

  • Patients were given tokens for tasks such as brushing their hair or making their bed.

  • Tokens could be exchanged for being allowed to listen to music, viewing a film, or visiting the canteen.

  • They found that the average number of daily chores completed increased from 5 to 42 within a few weeks.

• Cromer (2013) suggests that a major problem in assessing the effectiveness of token economies is that their use is uncontrolled.

  • When a token economy system is introduced in a psychiatric ward, all patients are in the program rather than having a token economy group and a control group who are not receiving the tokens.

• As such behavior can only be compared with their previous behavior rather than a control group

• This could be misleading as it could be other factors, e.g. increase in staff attention that causes the improvement rather than the tokens

  • Gynocentric, low temporal validity

• Therefore, this means that behaviour can only be compared with their previous behaviour rather than a control group and as such may mean that token economies are not as effective as research suggests.

weaknesses

• A limitation for the effectiveness of token economies is that research is yet to provide an answer to whether token economies actually work.

• There have been very few published randomised trials that have been carried out to support token economies as being effective in managing the symptoms of schizophrenia.

  • An explanation for this may be the file drawer problem. This leads to a bias towards positive published findings because undesirable results have been ‘filed away’.

• In an era of evidence-based medicine, this lack of support is considered unacceptable and so token economies have fallen out of use in many institutional care settings for people with schizophrenia in the developed world.

• This suggests that token economies could be successful if randomised trials could be carried out to give a definitive answer about their effectiveness.

 

• A limitation of the appropriateness of token economies is that they might not be useful for patients who are not living in an institution.

• Corrigan (1991) argues that there are problems administering the token economy method with outpatients who live in the community.

  • Within a psychiatric ward, inpatients receive 24-hour care and so there is better control for staff to monitor and reward patients appropriately.

  • Whereas, once patients are released token economies are not appropriate as patients will not be able to receive tokens for all behaviours.

• Token economies may therefore be vulnerable to extinction which would be a problem in the real world because the goal is to get patients to function independently.

• This means that as a result, even if token economies did produce positive results in institutions, they would not be maintained beyond that environment once patients are released.