Management of Schizophrenia

• What is a token economy?

  A form of behavioral modification
• How does a token economy encourage desirable behaviors?

  By using selective reinforcement
• What is the basis of token economies?

  Operant Conditioning
• What are tokens in a token economy?

  Secondary reinforcers
• When do tokens have value?

  Once learned to obtain primary reinforcers
• What are generalized reinforcers?

  Powerful secondary reinforcers for various primary reinforcers
• Who conducted the classic demonstration of a token economy?

  Ayllon & Azrin (1968)
• What was the setting of Ayllon & Azrin's token economy trial?

  A ward of women with schizophrenia
• What did participants receive for completing tasks in the token economy trial?

  A token embossed with ‘one gift’
• What was the outcome of the token economy trial by Ayllon & Azrin?

  The number of tasks carried out increased significantly
• Why have token economies declined in the UK?

  Due to community-based care growth
• What ethical issues are raised by token economies?

  Restricting rewards for people with mental disorders
• What is institutionalization in the context of mental health?

  Developing bad habits from prolonged hospitalization
• What are the three categories of institutional behavior identified by Matson et al (2016)?

  Personal Care, Condition-related Behaviours, Social Behaviour
• What are the benefits of modifying behaviors through token economies?

  • Improves quality of life
  • Normalizes behavior for community adaptation
• What evidence supports the effectiveness of token economies?

  Seven high-quality studies showed positive results
• What did Glowacki et al (2016) find in their studies?

  Reduction in negative symptoms and unwanted behaviors
• What is the file drawer problem in research?

  Bias towards positive published findings
• What is a concern with a small evidence base for token economies?

  Serious questions over effectiveness evidence
• What ethical issues arise from the use of token economies?

  Control over patient behavior by professionals
• What major factor has contributed to the decline of token economies?

  Legal action by families of patients
• What are alternative approaches to token economies for managing schizophrenia?

  • Art therapy as a pleasant experience
  • Recommended by NICE guidelines
  • Comparable evidence base without ethical issues
• What did Chiang et al (2019) conclude about art therapy?

  It may be a good alternative to token economies
• What are the risks associated with art therapy compared to token economies?

  Major risks of side effects or ethical abuses
• What is a strength for Token Economies?

  Evidence for Effectiveness

  • Glowacki et al (2016) identified 7 high quality studies published between 1999 and 2013 that examined the effectiveness of token economies for people with chronic mental health issue
  • All studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours
  • This supports the value of token economies 
• What is a limitation for Token Economies?

  File Drawer Problem

  • However, 7 studies is still a small evidence base to support the effectiveness of a technique
  • One issue with a small number of studies is the file drawer problem, where it leads to bias towards positive published findings because undesirable results have been ‘filed away’, which is a problem in reviews that only include a small number of studies
  • This means that there is a serious question over the evidence for the effectiveness of token economies
• What is a limitation for Token Economies?

  Ethical Issues

  • The use of token economies raises ethical issues because it gives professionals considerable power to control the behaviour of people in the role of the patient
  • This inevitably involves imposing one institution’s norms on to others, which is especially problematic if target behaviours are not identified sensitively, and legal action by families who see their relative in position has been a major factor in the decline in the use of token economies
  • This means that the benefit of token economies may be outweighed by their impact on personal freedom and short-term reduction in quality of life
• What is a limitation for Token Economies?

  Alternative Approaches

  • Even if token economies can be helpful for managing schizophrenia, there are other approaches with a comparable evidence base that do not raise the same ethical issues
  • Chiang et al (2019) concluded that art therapy may be a good alternative, as it is a pleasant experience without major risks of side effects or ethical abuses; NICE guidelines also recommend art therapy for schizophrenia
  • This means that art therapy might be a good alternative to token economies