management of schizophrenia

Question 1

Token economies

Answer 1

• 1st carried out by Ayllon & Azrin (1968) on women who were in a hospital
  
  • rewarded tokens embossed with ‘one gift’ for doing tasks such as making the bed or cleaning up
  • the tokens could be swapped for privileges such as watching a film
  • number of task they completed increased
• used extensively in the 60s & 70s as the norm was long-term hospitalisation
  
  • Due to community-based care & complex ethical issues regarding rewards for mentally ill patients, it has decreased
• used to manage schizophrenia in many parts of the world

Question 2

Rational for token economies

Answer 2

• prolonged hospitalisation may lead to institutionalised behaviours like bad hygiene, poor social skills etc
• Matson et al (2016) : identified 3 categories of institutionalised behaviours that are tackled by token economies: personal care, social behaviour and condition-related behaviours (apathy)
• modifying these behaviours doesn’t cure schizophrenia but has benefits such as:
  
  • improving quality of life when in a hospital setting (social interactions for a usually sociable person
  • normalises behaviour & makes it easier for people who have spent time in hospital to adapt to community life

Question 3

What is involved in token economies

Answer 3

• tokens in the form of coloured discs are given immediately to patients when they carry out desirable behaviours (getting dressed)
• personal targets will be set for each person so its important they get to know the patients
• the immediacy of reward is important because it prevents ‘delay discounting’ - the reduced effect of a delayed reward
• rewards could be objects like sweets/magazines activities like a film or a walk / an appointment with a social worker to discuss the future

Question 4

How do token economies work?

Answer 4

• example of behaviour modification
  
  • behaviour therapy based on operant conditioning
• tokens are secondary reinforcers
• only have value once the patient has leant that they can be used to get rewards
  
  • rewards = primary reinforcers
• for tokens to be secondary reinforcers they get paired with primary reinforcers
• at the start of token economy programme tokens & primary reinforcers are are done together

Question 5

AO3: evidence for effectiveness (S)

Answer 5

• negative symptoms among schizophrenic patients in hospitals
  
  • reduced frequency of unwanted behaviour as well
• 7 studies is small evidence & can suffer from file drawer problem
  
  • when there’s bias towards desirable results as undesirable results have been ‘filed away’
  • common problem with reviews that use a small number of studies

Question 6

AO3: ethical issues (W)

Answer 6

• gives significant power to professionals to control behaviours of patients
  
  • means that doctors may impose their own norms & values
  • e.g: patients may like to look scruffy or get up late but this isn’t seen as normal & the choice is stopped
• restricting rewards fro patients who don’t behave as desired may add more pressure/ stress to already distressed patients
  
  • has resulted in legal action by families which has led to a decline in use of token economies

Question 7

AO3: alternative approach (W)

Answer 7

• other treatments which may be more ethical may be used
• Chiang (2019): concluded that art therapy may be an alternative
  
  • art therapy is a high-gain, low risk approach to managing schizophrenia
  • even if benefits are modest , it’s a pleasant experience without major risks, side effects or ethical issues
• NICE recommends art therapy for patients

Question 8

AO3: benefits (S & W)

Answer 8

• people in hospitals may get the chance to love outside the hospital if their personal care & social interaction can be improved
  
  • perhaps the best way to achieve this is token economies

token economies outside of hospitals is difficult as its difficult to monitor target behaviours & provide rewards immediately