Management of schizophrenia

• What are token economies?

  • Used in psychiatric hospitals
  • Do not cure positive symptoms but can help with negative symptoms.
  • Based on the idea of operant conditioning and positive reinforcement- a behaviour will be repeated if it results in a reward.
  • Improves the patients quality of life and makes it more likely that they can live outside of a hospital.
• How were token economy systems developed?

  • Allyon and Azrin
  • Trialled a token economy system in a ward of women with SZ.
  • Every time patients carried out a task they were rewarded with tokens.
  • Tokens could then be swapped for ward privileges e.g watching a film
• When were token economies more popular?

  • 1960-1970s
  • When treating SZ was long-term hospitalisation
• Why has the use of token economies declined?

  • Due to the growth of community-based care
  • The closure of psychiatric hospitals and ethical issues raised by restricting rewards to people with mental disorders.
• How does institutionalisation occur?

  • Develops under circumstances of prolonged hospitalisation.
  • One outcome is that people often develop bad habits e.g lack of hygiene or stop socialising with others.
  • This is a response to living without routine or simple small pleasures.
• Who identified 3 categories of institutional behaviour?

  Matson et al

  1. Personal care
  2. Condition-related behaviours e.g apathy
  3. Social behaviour
• What benefits does token economies have?

  • Improves persons quality of life within the hospital setting.
  • Normalises behaviour which makes it easier for people who spent time in a hospital to adapt back to community life.
• Theory behind token economies

  • Tokens are secondary reinforcers as they have value once the person receiving them has learnt why they can be used to gain a meaningful reward.
  • Meaningful rewards are primary reinforcers
  • Tokens can be exchanged for a range of different primary reinforcers so are known as generalised reinforcers.
• Research support for token economies

  • Glowacki et al identified seven high quality studies published from 1999-2013 that examined the effectiveness of token economies for people who have chronic mental health issues.
  • All studies show a reduction in negative symptoms and a decline in the frequency of unwanted behaviours.
  • Therefore this shows that token economies are an effective methods in order to encourage desired behaviours.
• What ethical issues are associated with token economies?

  • Token economies give professionals considerable power to control the behaviour of patients. Involving imposing one persons norms onto others which is especially problematic if target behaviours are not identified sensitively.
  • Eg someone who likes to look scruffy and get up late may have their own personal freedom stopped, and simple pleasures. Legal action by families who see their relative in this position is a major factor in the decline in the use of token economies.
  • benefits may be outweighed by reduction in personal freedom
• What alternative approaches can be taken instead of token economies?

  • Chaing et al concluded that art therapy could be a plausible alternative. Although evidence is small, it shows that art therapy is a low risk approach to managing SZ.
  • NICE guidelines recommend art therapy for SZ as it does not cause major risk effects or ethical abus.
  • This shows that art therapy may be a good alternative to token economies.
• Why is is difficult to continue token economy system beyond the hospital setting?

  • Target behaviours cannot be monitored closely and tokens cannot be administered immediately.
  • Without accurate tracking of desired behaviours and immediate rewards in the form of tokens it is likely that the benefit of the token economy system will be lost.
  • The frequency of undesired behaviours will increase again.
• Why may is be useful to use token economy systems?

  • Some people with SZ may only get the chance to live outside the hospital if their personal care and social interaction can be improved.
  • Perhaps the best way to achieves this is using token economies during hospital care.
  • Even though there is a risk of token economy loosing its effect outside the hospital this is probably a risk worth taking for individuals who might otherwise remain institutionalised.