Management of schizophrenia

Question 1

What are token economies?

Answer 1

• Behavioural modification, in which desirable behaviours are encouraged by the use of selective reinforcement
• Reward systems

Question 2

What did Ayllon and Azrin find in their study on token economies?

Answer 2

• Trialled a token economy system in a ward of scz women
• Each time pps carried out a task (i.e. made bed/cleaned up), they were given a plastic token, embossed with the words- ‘one gift’
• Tokens may be swapped for ward privileges (i.e. watch film)

Question 3

When were token economies most commonly used?

Answer 3

• 1960s/70s when the norm for treating schizophrenia was long-term hospitalisation
• UK= use has now declined due to growth of community-based care, closure of psychiatric hospitals and ethical issues

Question 4

What is the rationale for token economies (institutionalisation)?

Answer 4

• Develops under prolonged hospitalisation
• One outcome- developing bad habits, i.e. cease to maintain good hygiene/stop socialising= understandable response to living without a routine/pleasures of everyday life

Question 5

What did Matson identify as the 3 categories of institutional behaviour, tackled by token economies?

Answer 5

1) Personal care
2) Condition-related behaviours (i.e. apathy)
3) Social behaviour

Question 6

What are the effects of modifying institutional behaviours?

Answer 6

1) Improve the individual’s quality of life within the hospital setting (i.e. makeup for someone who takes pride in their appearance)
2) Normalises behaviour, making it easier for people who have spent much time in hospital to adapt into life in the community (i.e. making their bed)

Question 7

What is involved in a token economy?

Answer 7

• Tokens given instantly to individuals who carry out desirable behaviours
• Cooper et al- target behaviours decided on an individual basis- important to know the person to idenfy the most appropriate target behaviours
• Tokens= no value, but are swapped for more tangible rewards
• Immediate reward is best as delayed= less effective
• Rewards include: objects (sweets, magazines), activities (film, walk), appointments with a social worker (plan life after hospitalisation)

Question 8

What is the theoretical explanation of token economies?

Answer 8

• Behaviour modification= behavioural therapy based on operant conditioning
• Tokens= secondary reinforcers (only have value once understood that they can be used to obtain meaningful rewards)
• May be swapped for primary reinforcers, so become generalised reinforcers
• Paired with primary reinforcers to become secondary reinforcers

Question 9

Strength-
I- Evidence for effectiveness

Answer 9

D- Glowacki et al identified 7 high quality studies published 1999-2013 that examined effectiveness of token economies for those with chronic mental health issues, and involved patients living in hospital settings. All studies showed a reduction in negative symptoms and a decline in frequency of unwanted behaviour
E- Supports the value of token economies

Question 10

Limitation-
I- Small evidence base

Answer 10

D- File drawer problem- leads to bias towards positive published findings as undesirable results have been ‘filed away’. This is particularly an issue with small sample studies
E- Means there is a serious question over the evidence for effectiveness

Question 11

Limitation-
I- Ethical issues

Answer 11

D- Raises ethical issues as it gives professionals considerable power to control behaviour of patients. This involves imposing one’s norms onto others, which is problematic if target behaviours are not identified sensitively. E.g: someone who liked looking scruffy/ getting up late may have these personal freedomes curtailed. Restricting the ability of pleasure for those who misbehave may have an even worse time than normal- may lead to legal action
E- Means benefits may be outweighed by the impact on personal freedom, and short-term reduction in quality of life

Question 12

Limitation-
I- Alternative approaches

Answer 12

D- There are other ethical approaches. Chiang et al concluded that art therapy is a good alternative. Evidence base is regularly small and has some methodological issues but appears to show that art therapy is a high-gain low-risk approach, and is a pleasant experience, without major risk of side ethics/ethical issues. NICE recommends art therapy
E- Means art therapy may be a better alternative to token economies

Question 13

Evaluation extra-
I- Benefits

Answer 13

D- Token economies are difficult to continue once a person is outside of a hospital setting, as target behaviours cannot be closely monitored and tokens cannot be administered immediately. Benefits will be lost and frequency of undesired behaviours will increase. However, some may only get the chance to improve outside of a hospital is personal care and social interaction is improved- through use of token economies
E- Suggests it is worth the issues around using token economies in hospitals to give people a chance outside hospitals