Management of Schizophrenia

• Token Economies for Schizophrenia

  - token economies are reward systems used to manage the behaviour of people with schizophrenia

  
  

  - this is particularly used for those who have developed maladaptive behaviour by spending too much time in psychiatric hospitals
• Developing Token Economies with Schzophrenia

  - (Ayllon & Azrin, 1968) trialled a token economy in a ward of women with schizophrenia

  
  

  - every time a participant carried out a task such as making their bed or cleaning up they were given a token embossed with the word 'one gift'

  
  

  - these tokens could be swapped for privileges such as being able to watch a film

  
  

  - the number of tasks carried out increased significantly
• Reduction in Token Economies

  - token economies were used extensively in the 1960s & 70s when long-term hospitalisation was the norm for treating schizophrenia

  
  

  - their use has declined with the growth of community-based care and the closure of many psychiatric hospitals

  
  

  - there are also ethical issues attached to them such as the restriction of rewards to people with mental disorders

  
  

  - however they remain a standard approach to managing schizophrenia in many parts of the world
• Rationale for Token Economies

  - people often develop bad habits as a result of institutionalisation, e.g. stop maintaining hygiene, stop socialising with others etc.

  
  

  - this is an understandable response to living without the routine and small pleasures we experience in everyday life
• Institutional Behaviour


  - (Matson et al, 2016) identified 3 categories of institutional behaviour:

  . personal care

  . institution related behaviour (e.g. apathy)

  . social behaviour

  
  

  - modifying this behaviour has 2 major benefits:

  . improves the person's quality of life in the hospital setting

  . normalises behaviour and makes those who have been in the hospital for long to adapt back to life in the community
• What is Involved in Token Economy

  - tokens in the form of coloured discs are immediately given to individuals when they carry out desirable behaviour

  
  

  - target behaviours are decided on an individual basis and it is important to know the person to identify these (Copper et al, 2007)

  
  

  - tokens are then immediately swapped for more tangible rewards, having an immediate reward is important as delayed rewards are less effective

  
  

  - rewards include things like magazines, sweets or access to activities like films or a walk outside
• Theoretical Understanding of Token Economies

  - token economies are an example of behaviour modification (behaviour therapy based on operant conditioning)

  
  

  - tokens are secondary reinforcers because they only have value once the person learns they can be used to obtain meaningful rewards (these rewards are primary reinforcers)

  
  

  - tokens that can be used to exchange for multiple primary reinforcers are particularly powerful and are called generalised reinforcers

  
  

  - in order for tokens to become secondary reinforcers they are paired with primary reinforcers so at the start of a token economy they are paired together
• Evidence for Effectiveness: Strength

  - (Glowacki et al, 2016) identified 7 high quality studies published between 1999 and 2013 examining the effectiveness of token economies

  
  

  - all studies showed a decline in negative symptoms and a decline in the frequency of unwanted behaviours

  
  

  - this supports the value of token economies
• Evidence for Effectiveness: Counterpoint


  - 7 studies is quite a small evidence base for the effectiveness of a technique

  
  

  - an 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 means there is a serious question over the evidence for the effectiveness of economies
• Ethical Issues: Limitation


  - token economies give professionals a considerable amount of power to control the behaviour of patients, inevitably this involves imposing one person's (or institution's) norms upon another

  
  

  - this is especially problematic if target behaviours aren't identified sensitively, restricting the availability of pleasures to seriously mentally ill people who don't behave in the desired way may exacerbate their distress

  
  

  - legal action for family members of such individuals has been a major factor in the decline of token economy use

  
  

  - this means the benefits of token economies may be outweighed by the impact on personal freedom and short-term reduction in quality of life
• Alternative Approaches: Limitation

  - there are other approaches with a comparable evidence base that don't raise the ethical issues token economies do

  
  

  - (Chiang et al, 2019) concluded art therapy may be a good alternative

  
  

  - the evidence base is small and has some methodological limitations but shows that art therapy is a high-gain low-risk approach to managing schizophrenia

  
  

  - even if the benefits are modest, so are most treatments/managements for schizophrenia and lack side effects such as ethical abuses

  
  

  - NICE guidelines recommend art therapy for schizophrenia
• Benefits: Evaluation Extra


  - token economies are difficult to continue once a person is outside of a hospital setting

  
  

  - this is because target behaviours can't be monitored closely and rewards given immediately

  
  

  - on the other hand, some people with schizophrenia may only get the chance to live outside the hospital if their personal care and social interaction can be improved

  
  

  - the best way to achieve this may be a token economy