eval token economy

Question 1

Evidence of effectiveness

Answer 1

One strength of token economies for the management of schizophrenila is evidence for their effectiveness.
Krista Glowacki et al. (2016) identified seven high quality studies published between 1999 and 2013 that examined the effectiveness of token economies for people with chronic mental health issues such as schizophrenia 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.
This supports the value of token economies.

Question 2

Counterpoint

Answer 2

Counterpoint However, seven studies is quite a small evidence base to support the effectiveness of a technique. 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 numbers of studies.
This means that there is a serious question over the evidence for the effectiveness of token economies.

Question 3

Ethical issues

Answer 3

One limitation with the use of token economies to manage schizophrenia is the ethical issues raised.
The use of token economies raises ethical issues because it gives professionals considerable power to control the behaviour of people in the role of patient. This inevitably involves imposing one person’s (or institution’s) norms on to others, which is especially problematic if target behaviours are not identified sensitively.
For example, someone who likes to look scrufly and get up late might have these personal freedoms curtailed. Perhaps more seriously, restricting the availability of pleasures (e.g. having sweets or seeing films) to people who don’t behave as desired means that seriously ill people, who are already experiencing 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 the use of token economies.
This means that the benefits of token economies may be outweighed by their impact on personal freedom and short-term reduction in quality of life.

Question 4

Alternative approaches

Answer 4

A further limitation of token economies is the existence of more pleasant and ethical alternatives.
Even if token economies can be helpful for managing schizophrenia there are
other approaches with a comparable evidence base tat do not raise me same ethical issues. For example, a review by Mathew Chiang et al. (2019) concluded that art therapy might be a good alternative. The evidence base is regularly small and has some methodological limitations, but it appears to show that art therapy is a high-gain low-risk approach to managing schizophrenia. Even if the benefits of art therapy are modest, this is generally true for all approaches to treatment and management of schizophrenia and, unlike alternatives, art therapy is a pleasant experience without major risks of side effects or ethical abuses. NICE guidelines recommend art therapy for schizophrenia.
This means that art therapy might be a good alternative to token economies.

Question 5

Benefits

Answer 5

One problem with token economies is that they are very difficult to continue once a person is outside a hospital setting. This is because target behaviours cannot be monitored closely and tokens cannot be administered immediately. Without accurate tracking of desired behaviours and immediate reward in the form of a token it is likely that the benefit of the token economy will be lost and the frequency of undesired behaviours will increase again.

On the other hand, some people with schizophrenia may only get the chance to live outside a hospital if their personal care and social interaction can be improved. And perhaps the best way to achieve this is using a token economy during hospital care. So even though there is a risk of the token economy losing its effect outside hospital this is probably a risk worth taking for individuals who might otherwise remain institutionalised.

This suggests that it is worth the issues around using token economies in hospital to give people a chance outside the hospital.