4.7. Management of Sz

Question 1

What are token economies?

Answer 1

• a form of therapy where desirable behaviours are encourages by the use of selective reinforcements
• behaviour can be shaped by the use of +ve and -ve reinforcers

Question 2

Who are token economies used on?

Answer 2

• they’re used on those who have developed patterns of maladaptive behaviour through spending long periods of time in psychiatric hospitals -> common to develop bad hygiene habits

Question 3

What do token economies do?

Answer 3

Improve quality of life, they are not a cure

Question 4

How did token economies develop?

Answer 4

• Ayllon and Azrin used token economies in an sz ward
• a gift token was given for every tidying act -> later swapped for privileges e.g. films
• used extensively during 1960s and 70s but then declined in UK due to a shift towards care in the community
• token economies remain a standard approach to managing sz in many parts of world

Question 5

What is the rationale for token economies?

Answer 5

• institutionalisation occurs in long term hospital treatment
• Matson et al identified 3 categories of institutional behaviour that can be tackled
  - personal care
  - condition related behaviour
  - social behaviour
• modifying these behaviours doesn’t cure but does have benefits
  - improved quality of life
  - normalises behaviour

Question 6

When are token economies given?

Answer 6

immediately after desirable behaviour which are individually based on a person

delayed rewards are less effective

Question 7

What do negative symptoms of sz lead to?

Answer 7

neglect of self care

token economy can be used to encourage positive behaviour using operant conditioning

Question 8

What are primary reinforcers?

Answer 8

anything that gives pleasure and is directly rewarding

Question 9

What are generalised reinforcers?

Answer 9

no value but can be swapped for a range of different primary reinforcers

Question 10

Strength: evidence of effectiveness

Answer 10

+ Glowacki et al identified 7 high quality studies published between 1999 and 2013 that examined the effectiveness of token economy for people with chronic mental health issues andw involved patients living in a hospital setting.
+ All studies showed a reduction in -ve symptoms and decline in the frequency of unwanted behaviours -> supports value

• However, 7 studies is a small evidence base to support effectiveness
• Leads to file drawer problem - bias towards positive published findings because undesirable results have been filed away

Question 11

Weakness: ethical issues

Answer 11

• gives professionals considerable power to control behaviour of people in role of patient
• involves imposing one person’s norms onto another which is problematic if target behaviours aren’t identified sensitively
• restricting availability of pleasures to people who don’t behave as desired means that seriously ill people who are already experiencing distressing symptoms have an even worse time
• families taking legal action has been a major factor in decline of token economies
• benefits may be outweighed by impact on freedom

Question 12

Weakness: alternative approaches

Answer 12

there are more pleasant and ethical alternatives

Mathew Chiang et al:
- concluded that art therapy may be a good alternative
- has some methodological issues and a small evidence base but it is a high-gain low-risk approach
- benefits are modest but lacks risks, side effects or ethical abuses
- NICE guidelines recommend art therapy for sz