management of schizophrenia Flashcards
what are token economies
reward systems used to manage behaviour of people with Sz
(especially those who have developed patterns of maladaptive behaviour from spending long periods of time in psychiatric hospitals)
who carried out the classic demonstration of a token economy
ayllon & azrin (1968)
how did ayllon & azrin (1968) demonstrate token economy systems
- trialled token economy system in ward of women with Sz
- each time they carried out positive task (eg. made bed, cleaned up) they were given a plastic token embossed with words ‘one gift’
- tokens could be swapped for ward privileges (eg. watch film)
- number of tasks carried out increased significantly
when were token economies most extensively used
1960/70s (long-term hospitalisation was main treatment for Sz)
why has token economy use decreased in the uk (since 1960/70s) as a management of Sz
- growth of community-based care
- closure of many psychiatric hospitals
- complex ethical issues raised by restricting rewards to people with mental disorders
when does institutionalisation develop
under circumstances of prolonged hospitalisation
potential outcome of institutionalisation
people often develop bad habitats (eg. stop maintaining good hygiene, stop socialising)
who identified 3 categories of institutional behaviour which is commonly tackled by token economies
mateson et al. (2016)
3 categories of institutional behaviour which is commonly tackled by token economies (identified by mateson et al. 2016)
- personal care
- condition-related behaviours (eg. apathy)
- social behaviour
2 major benefits of modifying behaviours using token economy systems identified by mateson et al. (2016)
doesn’t cure Sz but 2 major benefits:
1. improves individuals quality of life within hospital setting (eg. social interaction for someone’s who is usually sociable, make-up for someone who takes lots of pride in appearance)
2. ‘normalises’ behaviour which makes it easier for those who’ve spent a lot of time in hospital to adapt back into life in the community (eg. getting dressed in the morning, making their bed)
what is involved in a token economy
- tokens are given immediately to individuals when carry out desirable behaviour (or as soon as possible)
- target behaviours decided on individual basis & important to know person in order to identify most appropriate target behaviours for them (cooper et al. 2017)
- tokens swapped for more tangible rewards
- some form of immediate reward for target behaviour (tokens) is important as delayed rewards are less effective
- rewards in hospital setting eg. sweets, magazines, access to activities (eg. film, walk outside) or potentially an appointment with social worker to plan for life after
what are token economies an example of
behaviour modification (behavioural therapy based on operant conditioning)
describe token economies as behaviour modification (operant conditioning)
- tokens = secondary reinforcers (only have value once person receiving them has learnt they can be used to obtain meaningful rewards)
- meaningful rewards = primary reinforcers
- tokens exchanged for range of primary forcers (powerful secondary reinforcers = generalised reinforcers)
- to become secondary reinforcers, tokens must be paired with primary reinforcers (at start of token economy programme tokens/priary reinforcers administered together)
AO3 +) evidence for effectiveness of token economies in management of Sz
E:
- glowacki et al. (2016) identified 7 high quality studies published 1999-2013 which examined effectiveness of token economies for those with chronic mental health issues (including Sz) & involved patients living in hospital setting
- all studies showed reduction in negative symptoms & decline in frequency of unwanted behaviours
T: supports value of token economy systems
AO3 -) counterpoint to evidence for effectiveness of token economy systems in managing Sz
E:
- 7 studies is small evidence base to support effectiveness of technique
- file drawer problem = leads to bias towards positive published findings as undesirable results have been ‘filed away’
- particular problem in reviews which only include small number of studies
T: means there’s a serious question over evidence for effectiveness of token economy systems
AO3 -) ethical issues raised regarding use of token economies to manage Sz
E:
- gives professionals considerable power to control behaviour of patients
- inevitably involves imposing one persons/institutions norms on to others = problematic if target behaviours aren’t identified sensitively (eg. someone who prefers looking scruffy/getting up late has personal freedoms curtailed)
- restricting availability of pleasures (eg. sweets, watching films) to those who don’t behave as desired means seriously ill people (already experiencing distress) have even worse time
- legal action by families who see relatives in this position has been major factor in decline of token economy systems
T: means benefits of token economies may be outweighed by impact on personal freedom & short-term reduction on quality of life
AO3 -) existence of more pleasant & ethical alternatives
E:
- review by chiang et al. (2019) concluded art therapy may be good alternative
- evidence base is regularly small & has methodological limitations, but appears to show art therapy has high-gain low-risk approach to managing Sz
- even if benefits are modest, this is mostly true for all approaches to treatment/management of Sz & (unlike alternatives) art therapy is pleasant experience without major risks of side effects/ethical abuses
- NICE guidelines recommend art therapy for Sz
T: means art therapy may be good alternative to token economies
