8. management of schizophrenia

Token economies — a form of behavioural modification, desirable behaviours are encouraged by the use of selective reinforcement. The token are secondary reinforcers which are then exchanged for primary reinforcers

Developing token economies

  • Ayllon and Azrin trialled a token economy in a ward of women with schizophrenia

  • Found positive tasks increased significantly

  • Were used a lot in the 1960s and 70s when the norm for treating schizophrenia was long-term hospitalisation

  • This has declines due to the growth of community based care and the closure of many psychiatric hospitals, also because of ethical issues from restricting rewards to people with mental disorders

Rationale for token economies

  • institutionalisation develops from prolonged hospitalisation

  • Outcome is that people develop bad habits from living without a routine and without small pleasures we experience in daily life

  • Matson identified 3 categories of institutional behaviour: personal care, condition-related behaviour (e.g apathy) and social behaviour

  • These are tackled by token economies, modifying these behaviour doesnt cure schizophrenia but it has 2 major benefits

  1. Improves the persons quality of life within the hospital

  2. Normalises behaviour and makes it easier for people to adapt back into life in the community

What’s involved

  • the tokens are immediately given to individuals when they have carried out a desirable behaviour. Must be immediate because delayed rewards are less effective

  • Target behaviours are decided on an individual basis

  • Tokens are then swapped for tangible rewards

Theoretical understanding

  • based on operant conditioning

  • Token are secondary reinforcers because they only have value once its learned they can be used to obtain rewards

  • The rewards are primary reinforcers

Evaluation

Evidence of effectiveness

  • Glowacki investigated 7 studies that examined the effectiveness of token economies for those with chronic mental health issues such as schizophrenia

  • All studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours

— counterpoint — small sample of 7 studies. This leads to the ‘file drawer problem’, leads to a bias towards positive published findings because undesirable findings have been “filed away’

Ethical issues

  • Professionals control the behaviour of the patient however this involved imposing on persons ‘norms’ onto others

  • Also restricting rewards can be harmful, especially towards those who are mentally ill and are experiencing distress

  • So benefits might be outweighed by their impact on personal freedom and short term reduction in quality of life

Alternative approaches

  • Chiang found art therapy is a good alternative for managing schizophrenia, which doesnt have side effects or ethical abuses

  • However the evidence base is regularly small and has some methodological limitations

Benefits

  • lack real world application and cannot be continued once the person is outside the hospital. Due to not being able to monitor them closely or administer tokens immediately, so not good for long term management

  • However those with schizophrenia will only live out of the hospital once their personal care and social interaction is improved, this is best achieved through token economies. In hopes they will not require it outside of hospital