Management of Sz

• Token Economies

  Token economies are a form of behavioural modification, where desirable behaviours are encouraged by the use of selective reinforcement. For example, people are given rewards when they engage in socially desirable behaviours. They are secondary reinforcers and can then be exchanged for primary reinforcers- food or privileges
• Token economies


  Token economies are a form of behavioural modification, where desirable behaviours are encouraged by the use of selective reinforcement. For example, people are given rewards when they engage in socially desirable behaviours. They are secondary reinforcers and can then be exchanged for primary reinforcers- food or privileges
• Allon and Arizin (1968)


  Allon and Arizin (1968) trialled a token economy system in a ward of women with Sz. Every time they carried out a task such as making their bed or cleaning up they were given a plastic token that could be exchanged for ward privileges such as being able to watch a film. This increased the number of tasks completed significantly.
• When Token economies were used most


  The system was used extensively in the 1960s-70s when the norm for treating Sz was long-term hospitalisation. Their use has declined in the UK partly because of the growth of community-based care and the closure of many psychiatric hospitals, but also because of ethical issues of restricting rewards to people with mental disorders. However, they remain a standard approach to managing Sz in many parts of the world.
• Reasoning behind token economies 


  Mason et al. (2016) identified three categories of institutional behaviour commonly tackled by token economies: personal care, condition-related behaviours and social behaviour. It can help to:

  • Improve the person's quality of life within the hospital setting, for example, make-up for someone who cares about their appearance.
  • 'Normalises' behaviour and makes it easier for people who have spent time in a hospital to adapt back into life in the community, for example getting dressed in the morning or making their bed.

   
• Institutionalisation and Outcomes


  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 being stripped of normal routine and simple life pleasures.
• What token economies involve

  Tokens (secondary reinforcers) are given immediately after someone carries out a desirable behaviour. Immediately is more effective than when they are delayed. These behaviours are decided on an individual basis. The tokens can then be exchanged for tangible meaningful rewards (primary reinforcers) such as the ability to watch a film or sweets. As the tokens can be exchanged for a variety of primary reinforcers they are 'generalised reinforcers'.
• Token Economies as behavioural modification

  Token economies are an example of behavioural modification- a behavioural therapy based on operant conditioning. Using the principles of rewards to encourage behaviour.
• A Strength of token economies to manage Sz

  One strength is evidence of their effectiveness. Glowacki et al (2016) 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 Sz and involved patients in hospital settings. All studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours. This supports the value of token economies.
• Limitation of support for token economies


  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. The 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 number of studies. This means there is a serious question over the evidence for the effectiveness of token economies.
• Ethical limitation of token economies


  It gives professionals considerable power to control patients. This involves imposing one person or institution's norms onto others, which is an issue if target behaviours are not identified sensitively. If someone likes to dress scruffy and get up late, this may be discouraged. Giving rewards only to those who behave as desired means seriously ill people who are already experiencing distressing symptoms, have it even worse. Some families took legal action due to this. This means that the benefits may be outweighed by their ethical issues.
• A limitation of token economies is the existence of more pleasant, more ethical alternatives


  Chiang et al. (2019) concluded in a review, that art therapy may be a good alternative. The evidence base is relatively small and has the same methodological limitations, but it appears to show that art therapy is a high-gain low-risk approach to managing Sz. It is a pleasant experience, without major risks or ethical issues. NICE guidelines recommend art therapy for Sz. This means that art therapy may be a good alternative to token

  economies.
• Use of token economies outside of hospitals

  •  One problem with token economies is they are difficult to continue once a person is outside of the hospital. This is because target behaviours cannot be monitored closely and tokens cannot be administered immediately.
  •   On the other hand, some people with Sz may only get the chance to live outside of the hospital if their personal care and social interaction improve. And token economy can help achieve this.