Management of schizophrenia

• Token economies are reward systems used to manage the behaviour of people with schizophrenia, in particular those who have developed patterns of maladaptive behaviour through spending long periods in psychiatric hospitals.
• Ayllon and Azrin trialled a token economy system in a ward of women with a diagnosis of schizophrenia. Every time the participants carried out task such as making their bed or cleaning up they were given a plastic token embossed with the words ‘one gift’. These tokens could then be swapped for ward privileges. The number of tasks carried out increased significantly.
• Token economies were extensively used in the 1960s and 70s when the norm for treating schizophrenia was long-term hospitalisation. Their use has now declined in the UK, partly because of the growth of community-based care and the closure of many psychiatric hospitals, but also because of the complex ethical issues raised by restricting rewards to people with mental disorders. However token economies still remain a standard approach to managing schizophrenia in many parts of the world.
• Institutionalisation develops under circumstances of prolonged hospitalisation. One outcome is that people often develop bad habits, for example they might cease to maintain good hygiene or stop socialising with others. This is an understandable response to living without the kind of routine and small pleasures we experience in everyday life.
• Matson et al. identify three categories of institutional behaviour commonly tackled by means of token economies: personal care, condition-related behaviours (e.g. apathy) and social behaviour.
• Modifying these three behaviours identified by Mason et al. does not cure schizophrenia but it has two major benefits:

  1. improves the person's quality of life within the hospital setting (e.g. makeup for someone who usually takes a lot of pride in their appearance or social interaction for a usually sociable person)
  2. 'normalises' behaviour and this makes it easier for people who have spent a time in hospital to adapt back into life in the community, for example getting dressed in the morning or making their bed
• The idea is that tokens are given immediately to individuals when they have carried out a desirable behaviour. Target behaviours are decided on an individual basis and it is important to know the person in order to identify the most appropriate target behaviours for them (Cooper et al.). Although the tokens have no value in themselves they are swapped later for more tangible rewards. Having some form of immediate reward for target behaviour is important because delayed rewards are less effective. Tokens are therefore administered as soon as possible after a target behaviour.
• Token economies are an example of behaviour modification - a behavioural therapy based on operant conditioning. Tokens are secondary reinforcers because they only have value once the person receiving them has learned that they can be used to obtain meaningful rewards. These meaningful rewards are primary reinforcers.
• Tokens that can be exchanged for a range of different primary reinforcers are particularly powerful secondary reinforcers. Such secondary reinforcers are called generalised reinforcers.
• In order for the tokens to become secondary reinforcers they are paired with primary reinforcers, so at the start of a token economy programme tokens and primary reinforcers are administered together.
• A strength of token economies is evidence for their effectiveness. Glowacki et al. identified seven high quality studies published between 1999 and 2013 that examined the effectiveness of token economies for people with chronic mental health issues such as schizophrenia and involved patients living in a hospital setting. All the studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours. This supports the value of token economies.
• However, seven studies is quite a small evidence base to support the effectiveness of a technique. One issue with a small number of studies is the file drawer problem. This phenomenon leads to a bias towards positive published findings because undesirable results have been 'filed away'. This is a particular problem in reviews that only include a small numbers of studies. This means there is a serious question over the evidence for the effectiveness of token economies.
• The use of token economies raises ethical issues because it gives professionals considerable power to control the behaviour of people in the role of patient. This inevitably involves imposing one person's norms on to others, which is especially problematic if target behaviours are not identified sensitively. For example, someone who likes to look scruffy and get up late might have these personal freedoms curtailed.
• More seriously, 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 relative in this position has been a major factor in the decline in the use of token economies. This means that the benefits of token economies may be outweighed by their impact on personal freedom and short-term reduction in quality of life.
• Another limitation of token economies is the existence of more pleasant and ethical alternatives. Chiang et al. concluded that art therapy might be a good alternative. The evidence base is regularly small and has some methodological limitations, but it appears to show that art therapy is a high-gain low-risk approach to managing schizophrenia. Even if the benefits of art therapy are modest, this is generally true for all approaches to treatment and management of schizophrenia and, unlike alternatives, art therapy is a pleasant experience without major risks of side effects or ethical abuses.