token economies

• The use of token economies is based on the principles of operant conditioning and was developed as a way to deal with negative symptoms and maladaptive behaviours and promote more functional behaviours from patients. The therapy does not cure schizophrenia however its aim is to improve the quality of life and make it easier for them to function outside the institutional setting.
• Tokens are given to patients immediately when they display desirable behaviours that are targeted for reinforcement. Functional behaviours may vary dependent on the patients individual behavioural issues but could include getting dressed or making their bed.
• Giving a reward as soon as the desirable behaviour is displayed by the patient is important as this prevents “delay discounting” which reduces the effects if a reward is delayed. As a result of this process of classical conditioning, these neutral tokens become secondary reinforcers and so can be used to modify behaviours.
• Tokens that patients gather can be swapped for tangible rewards which vary but can include sweets, cigarettes, magazines or privileges within the institution. The idea is that patients will then engage more often with desirable behaviours voluntarily because they become associated with these rewards.
• Additionally undesirable behaviours can also be removed by removing any reinforcers that maintain it and restructuring the environment so the undesirable behaviour is no longer reinforced allowing token economies to reinforce only desired behaviours. This treatment assumes the behaviour can then be carried on and maintained outside the hospital setting too.
• A strength of token economies is that they have been shown to be effective in improving the functioning and motivation of patients with schizophrenia, particularly those with chronic symptoms in institutional settings. For example, Allyon and Azrin (1968) demonstrated that patients in a psychiatric hospital were able to increase their desirable behaviours, such as personal hygiene and social interaction, when rewarded with tokens that could be exchanged for privileges.
• This suggests that token economies can help patients re-learn adaptive behaviours that may have been lost due to institutionalisation. Furthermore, token economies are relatively easy to implement and can lead to immediate improvements in behaviour, which can help reduce staff stress and improve ward atmosphere. This practical benefit supports the use of behavioural therapies alongside more biologically-focused treatments.
• From an ethical perspective, token economies have been criticised for being manipulative and potentially infringing on patients’ human rights. For example, basic rights such as access to food, privacy, or movement may be made conditional on specific behaviours, which can be viewed as coercive, especially when used with vulnerable individuals who may lack full capacity to consent.
• Additionally, from a deterministic standpoint, the approach assumes that behaviour is entirely shaped by environmental reinforcement, ignoring the role of free will or internal mental processes. This reductionist view may overlook the complexity of schizophrenia and fails to address the root causes of the disorder, such as biological or cognitive factors. Thus, while token economies may have short-term benefits in managing behaviour, they may lack depth as a standalone treatment and raise important concerns about autonomy and dignity.
• One key strength of token economies is their practical utility in long-term psychiatric institutions, where patients may have become disempowered or disengaged due to prolonged hospitalisation. Token economies help encourage self-care, routine, and independence, which are essential for improving quality of life and preparing patients for discharge into the community. By reinforcing desirable behaviours such as getting dressed or engaging in group activities, patients may regain a sense of agency and structure. This makes token economies particularly valuable as a management tool, rather than a cure, supporting wider treatment plans and improving overall functioning.