Management of schizophrenia Flashcards
Token economies for schizophrenia
Token economies are a type of behaviour modification, where desirable behaviours are encouraged by the use of selective reinforcement. They are used to manage the behaviour of people with schizophrenia.
Developing token economies with schizophrenia
A demonstration of token economy was carried out by Ayllon and Azrin (1968). They trialled a token economy system in a ward of women with schizophrenia where each time the women carried out a task such as making their bed they were given a token. The tokens could be swapped for ward privileges. The number of tasks carried out increased significantly.
Token economies were greatly used in 60s and 70s when long term hospitalisation was the norm for treating schizophrenia, their use has now declined.
Rationale for token economies
Institutionalisation develops under circumstances of prolonged hospitalisation. One outcome is people often develop bad habits, such as poor hygiene, due to living without the routines we experience in everyday life.
Matson et al (2016) identified three categories of institutional behaviour commonly tackled by token economies: personal care, condition-related behaviours (apathy) and social behaviour.
Modifying these behaviours doesn’t cure schizophrenia but has two major benefits:
- Improves the persons quality of life within the hospital setting, for example social interaction for a usually sociable person
- ‘Normalises’ behaviour and this makes it easier for people who have spent time in hospital to adapt back to life in the community. E.g. getting dressed in the morning.
What is involved in a token economy?
The idea is that tokens are given immediately for individuals when they have carried out a desirable behaviour. Target behaviours are decided on an individual basis. The tokens are swapped later for more tangible rewards. Tokens are administered as soon as possible after a target behaviour as delayed rewards are less effective. Rewards may include sweets, watching a film etc.
Theoretical understanding of token economies
Token economies are an example of behaviour modification – a behavioural therapy based on operant conditioning.
Tokens are secondary reinforcers because they only have value once the person receiving them has learned that they can be used to gain meaningful rewards.
These meaningful rewards are primary reinforcers.
In order for the tokens to become secondary reinforcers they are paired with primary reinforcers.
Evaluation of token economies (brief)
:) evidence for effectiveness Glowacki HOWEVER file drawer problem
:( ethical issues
:( alternative approaches Chiang
strength of token economies
evidence for effectiveness of token economies in management of schizophrenia. 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 frequency of unwanted behaviours. This supports the value of token economies. 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 leads to a bias towards positive published findings because undesirable results have been ‘filed away’. This means that there is a serious question over the evidence for the effectiveness of token economies.
weaknesses of token economies
one limitation of the use of token economies to manage schizophrenia is the ethical issues raised. Token economies gives professionals considerable power to control behaviour. This inevitably involves imposing one person’s norms on to others, which is especially problematic if target behaviours aren’t identified sensitively. For example, someone who likes to get up late might have these personal freedoms taken away. Additionally, restricting the availability of pleasures to those who don’t behave in a desired way means seriously ill people, who are already experiencing distressing symptoms, have an even worse time. 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.
another limitation of token economies is the existence of more pleasant and ethical alternative approaches. Chiang et al (2019) concluded that art therapy may 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 the case for all approaches to treatment and management of schizophrenia. Unlike alternatives, art therapy is a pleasant experience without major risks of side effects or ethical issues. NICE guidelines recommend art therapy for schizophrenia. This suggests that art therapy may be a good alternative to token economies.
