management of schizophrenia

• token economies?

  form of behavioural modification where desirable behaviours are encouraged by the use of selective reinforcement. e.g. people are given rewards when they engage in socially desirable behaviours. the tokens are secondary reinforcers and can be exchanged for primary reinforcers.
• strength of token economies ?

  P - evidence for its effectiveness

  E - glowacki et al identified 7 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 living in a hospital setting. all the studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours.

  L - supports the value of token economies
• CA for strength of token economies?

  P - 7 studies is a small evidence base to support effectiveness of a technique.

  E - one issue with a small number of studies is the file drawer problem. this 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.

  L - there's a serious question over the evidence for the effectiveness of token economies.
• limitation for use of token economies?

  P - Ethical issues raised

  E - gives professionals considerable power to control the behaviour of people in the role of patient. this inevitably involves imposing one persons norms on to others. someone who likes to look scruffy and wake up late might have these personal freedoms curtailed. restricts availability of pleasures to people who don't behave as desired means that seriously ill people who already experience distressing symptoms have an even worse time. legal action by families who see their relative in this position has been a major factor in the decline in use of token economies.

  L - benefits of token economies may be outweighed by their impact on personal freedman short term reduction in quality of life.
• another limitation of token economies?

  P - existence of more pleasant and ethical alternatives.

  E - other approaches with a comparable evidence base that doesn't raise the same ethical issues. Chiang et al concluded that art therapy might be a good alternative. evidence base is small and has some methodological limitations but shows that art theory is a high gain low risk approach to managing SZ. even if the benefits of art therapy are modest this is generally true for all approaches to treatment and management of SZ. art therapy is a pleasant experience without major risks of side effects or ethical abuses. NICE guidelines recommends art therapy for SZ.

  L - art therapy might be a good alternative to token economies.
• Developing token economies with schizophrenia?

  -ayllon and azrin trialled a token economy in a ward of women with SZ.

  -Every time the participants carried out a task such as making their bed or cleaning up they were given a plastic token embossed with the words one gift. These tokens could then be swapped out for ward privileges. The number of tasks carried out increased significantly.

  -Token economies extensively used in the 1960s-70s when the norm for treating schizophrenia was long-term hospitalisation. use has now declined in the UK, because of community-based care and closure of psychiatric hospitals, and ethical issues raised by restricting rewards to people with mental disorders.
• Rationale for token economies?

  -One outcome of institutionalisation is that people often develop bad habits, e.g. might cease to maintain good hygiene or stop socialising with others.

  -Matson et al identified 3 categories of institutional behaviour commonly tackled by means of token economies: personal care, condition-related behaviours and social behaviour.

  Modifying these behaviours does not cure schizophrenia but it has two major benefits:

  1. Improves the person's quality of life within the hospital setting
  2. 'Normalises' behaviour and this makes it easier for people who have spent a time in hospital to adapt back into life in the community.
• What is involved in a token economy?

  -Target behaviours are decided on an individual basis and it is important to know the person to identity most appropriate target behaviours for them.

  -tokens have no value in themselves but they're swapped later for more tangible rewards.

  -Having some form of immediate reward for target behaviour is important as delayed rewards are less effective. therefore administered ASAP after a target behaviour.

  -Rewards in a hospital setting might include objects like sweets or magazines, or access to activities.
• Theoretical understanding of token economies?

  -Tokens are secondary reinforcers as they only have value once the person receiving them has learned that they can be used to obtain meaningful rewards.

  -These meaningful rewards are primary reinforcers. these tokens that can be exchanged for a range of different primary reinforcers are particularly powerful secondary reinforcers. Such secondary reinforcers are called generalised reinforcers.

  -In order for the tokens to become secondary reinforcers they are paired with primary reinforcers, so at the start of a token economy programme tokens and primary reinforcers are administered together.