Management of schizophrenia

• Token economies

  • Ayllon and Azrin used token economy systems on schizophrenic people. Every time the participant carried out a task they were given a token which could be exchanged for ward privileges.
  • The number of tasks carried out increased significantly.
  • Token economies used when the norm for treating schizophrenia was long-term hospitalisation.
  • The use has declined due to closing psychiatric hospitals and ethical issues by restricting rewards to people with mental disorders.
• Token economies= A form of behavioural modification, where desirable behaviours are encouraged by the use of selective reinforcement.
• Rationale for token economies

  • Institutionalisation develops under prolonged hospitalisation.
  • One outcome is that people often develop bad habits.
  • Matson identified 3 categories of institutional behaviour: personal care, condition related behaviours and social behaviour.
  • Benefits of modifying these behaviours: improves the persons quality of life within the hospital setting and it normalises behaviour and this makes it easier for people who have spent time in hospital to adapt back into life in the community.
• What is involved in token economy

  • Idea that tokens are given out 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 behaviour for them.
  • Have some sort of immediate reward for target behaviour is important because delayed rewards are less effective. Token are therefore administered as soon as possible after a target behaviour.
• Theoretical understanding of token economies

  • 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 recieving them has learned that they can be used to obtain meaningful rewards.
  • These meaningful rewards are primary reinforcers.
  • The secondary and primary reinforcers are paired together.
• Evaluation- evidence for effectiveness

  • Glowacki identified 7 high quality studies that examined the effectiveness of token economies for people with chronic mental health issues like schizophrenia and involved patients living in a hospital setting.
  • All studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours.
  • So supports the value of token economies.
• Evaluation- counterpoint

  • 7 studies is 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 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 number of studies.
  • So there is a serious question over the evidence of the effectiveness of token economies.
• Evaluation- ethical issues

  • It gives professionals considerable power to control the behaviour of people in the role of patient. This inevitably involves imposing one persons norms onto others, which is problematic if target behaviours are not identifies sensitively.
  • Eg; may make symptoms worse in restricting the availability of pleasures to people who don't behave as desired in mental ill people.
  • Legal action by families has been a major factor in the decline in the use of token economies.
  • Benefits may be outweighed by their impact on personal freedom and reduction in quality of life.
• Evaluation- alternative approaches

  Limitation= existence of more pleasant and ethical alternatives.

  • There are other approaches with a comparable evidence base that do not raise the same ethical issues.
  • Chiang concluded that art therapy might be a good alternative. It appears to show that art therapy is a high gain, low risk approach to managing schizophrenia. Even if the benefits are modest, art therapy is a pleasant experience with risks of side effects or ethical abuses.
  • NICE guidelines recommend art therapy for schizophrenia.