Token Economy

What is token economy?

A reward system used to manage the behaviour of those with schizophrenia - in particular those who have developed patterns of maladaptive behaviour through spending long periods in psychiatric hospitals / institutions

Ayllon and Azrin (1968)

Classic demonstration of token economy. Trialled token economy system in ward of women with schizophrenia diagnosis. Every time PPS carried out tasks (e.g., making their bed, cleaning up), given a plastic token embossed with ‘one gift’

Tokens could be swapped out for ward privileges (like watching a film)

Number of tasks carried out increased significantly - from 5 chores per day to 40

Matson et al (2016)

Identified 3 categories of institutional behaviour commonly tackled by token economies:

• personal care

• condition-related behaviours (e.g., apathy)

• social behaviour

Modifying these behaviours doesn’t cure schizophrenia, but has two major benefits:

1. improves person’s quality of life within the hospital setting

2. ‘normalises’ behaviour and makes it easier for people who’ve spent time in hospital to adapt back into life in the community

Cooper et al (2007)

Target behaviours decided on an individual basis. Important to know the person in order to identify the most appropriate target behaviour for them.

Why is immediate reward important?

Some form of immediate reward for target behaviour is important because delayed rewards are less effective

Tokens therefore administered as soon as possible after a target behaviour

Examples of rewards in hospital settings

• sweets

• magazines

• access to activities (films, walking outside)

• appointment with social workers to plan for life after hospitalisation

What are token economies based on?

Example of behaviour modification - a behaviour therapy based on operant conditioning

Primary + Secondary Reinforcers

Tokens are secondary reinforcers - only have value once the person receiving them has learned they can be used to obtain meaningful rewards

Meaningful rewards are primary reinforcers

In order for tokens to become secondary reinforcers, they’re paired with primary reinforcers. At start of a token economy programme, tokens and primary reinforcers are administered together

Strengths

Supportive Evidence

• Glowacki et al (2016)

Glowacki et al (2016)

Supportive Evidence

Identified 7 high quality studies published 1999 - 2013. All studies showed reduction in negative symptoms and a decline in the frequency of unwanted behaviours

Supports the value of token economies

Glowacki et al (2016) LIMITATION

7 studies quite small evidence base to support the effectiveness of a technique. An issue with small sample of studies is the file drawer problem - leads to bias in positive published findings because undesirable results have been ‘filed away’

A particular problem in reviews that only include a small number of studies

Means there’s a serious question over evidence for the effectiveness of token economies

Limitations

Ethical Issues

Alternative Approaches

• Chiang et al (2019)

Clinical Settings

Ethical Issues

Gives professionals considerable power to control the behaviour of people in the role of a patient. Inevitably involves imposing one person or institution’s norms on to others - especially problematic if target behaviours aren’t identified sensitively

Restricting the availability of pleasures to people who don’t behave as desired means that seriously ill people who are already experiencing distressing symptoms, have an even worse time

Legal action by families who see their relatives in this position has been major factor in decline of use of token economies

Means benefit of token economies can be outweighed by their impact on personal freedom and short-term reduction in quality of life

Alternative Approaches

Limitation of token economies is the existence of more pleasant and ethical alternatives

Chiang et al (2019) concluded art therapy a better alternative. Shows art therapy is a high-gain, low-risk approach to managing schizophrenia. Unlike alternatives, art therapy is a pleasant experience without major risks of side effects or ethical abuses

NICE guidelines recommend art therapy for schizophrenia

Means art therapy may be a good alternative to token economies

Clinical Settings

Token economies only likely to work in clinical settings, where patients can be constantly monitored and the systems of rewards is closely controlled

Limits the usefulness of token economies in treating schizophrenia long-term. What happens when the patient is discharged from hospital? May struggle more