management of schizophrenia

• Development of token economies

  • allyon and Azrin (1968) used a token economy in a schizophrenia ward. A gift token was given for every tidying act. Token were later swapped for privileges e.g. films
  • token economies were extensively used in the 1960s and 70s. decline in the UK due to a shift towards care in the community rather than hospitals and because of ethical concerns.
  • Token economies still remain a standard approach to managing schizophrenia in many parts of the world
• rationale for token economies

  • institutionalisation occurs in long term hospital treatment
  • matson (2016) identified 3 category of institutional behaviour that can be tackled using token economies; personal care, condition related behaviours e.g. apathy and social behaviour
  • modifying these behaviours does not cur schizophrenia but has 2 major benefits
• benefits of token economies

  1. token economies improve the quality of life within the hospital setting e.g. becoming more sociable with other residents
  2. encourages return to more normal behaviour, making it easier to adapt back into the community e.g. making your bed
• what is involved in a token economy

  • tokens are given immediately after a desirable behaviour is performed
  • target behaviours are decided individually based on knowledge of the person (Cooper 2007)
  • token have no value themselves but are swapped for rewards e.g. sweets, magazines, films
  • token are given immediately following target behaviours because delayed rewards are less effective
• the theory behind token economies - operant conditioning

  • token economies are an example of behaviour modification based on operant conditioning
  • tokens are secondary reinforcers - exchanged for rewards (primary reinforcers)
  • tokens that can be exchanged for a range of different primary reinforces are called generalised reinforcers. these have a more powerful effect
• one strength of token economies is evidence for their effectiveness

  Glowacki (2016) identified 7 high quality studies published between 1999 and 2013 on the effectiveness of token encomies in a hospital setting. all the studies showed a reduction in negative symptoms and a decline in frequency of unwanted behaviours. this supports the value of token economies
• one strength of token economies is evidence for their effectiveness: countepoint

  however, 7 studies is quite a small evidence base. one issue with such a small number of studies in the file drawer problem, - a bias towards publishing positive findings. this means that there is a serious question over the effectiveness of token economies
• one limitation is the ethical issues raised 


  professionals have the power to control peoples behaviour and this means imposing one persons norms onto others e.g. a patient may like to look scruffy. also restricting the availability of pleasures to people who don’t behave as desired means that very ill people, already experiencing distressing symptoms have an even worse time. this means that benefits of token economies may be outweighed by the impact on freedom and short term reduction in quality of life
• another limitation is the existence of more pleasant and ethical alternatives 


  other approaches do not raise ethical issues e.g. art therapy is a high gain low risk approach to managing schizophrenia (Chiang 2019). even if the benefits of art therapy are modest, this is true for all approaches to treatment and management of schizophrenia and art therapy is a pleasant experience. this means that art therapy might be a good alternative to token encomies - no side effects or ethical abuses.